Gastroenterology Coding Alert

Question: An elderly or handicapped patient is admitted the day before surgery for prep. The procedure is performed the next day, and the patient is discharged. Should I consider the patient's status outpatient, or how should I code the observation and the discharge?

Rhode Island Subscriber

Answer: First, you must consider the global surgical period for the procedure. If the procedure is an endoscopic or minor procedure, which has 000 or 010 global days, you may report the preoperative service on the day before surgery, if the gastroenterologist sees the patient on the admission day and clearly documents the extenuating circumstances. If the procedure is a major surgery, which has 90 global days, the preoperative care is included in the procedure fee.

Your scenario seems to describe an unusual reason necessitating increased preoperative care. For example, a patient is scheduled for an upper gastrointestinal endoscopy (EGD) for esophageal reflux. Because the person has Alzheimer's, the gastroenterologist is concerned the patient may not follow preoperative instructions and admits the patient to the hospital the day before surgery and evaluates him that day. The gastroenterologist performs the procedure on day two and discharges the patient.

For day one, report the appropriate initial hospital care code (99221-99223). Link the code to the reason for the endoscopy, esophageal reflux (530.81), and the underlying conditions, Alzheimer's (331.0). For the procedure, assign EGD code 43234 (Upper gastrointestinal endoscopy, simple primary examination [e.g., with small diameter flexible endoscope] [separate procedure]).

Do not bill for the discharge, because the relative value units for the procedure include a related E/M service. If the doctor admits the patient to observation status, use initial observation care codes (99218-99220). Do not assign observation care discharge (99217) or observation or inpatient care services (99234-99236). These codes include the discharge, so billing them with the EGD would represent double billing for the discharge services.

This scenario stipulates that the physician see the patient on the admittance day. In contrast, suppose the gastroenterologist has the patient admitted the day or evening before the procedure. The physician gives orders over the phone and does not see the patient on the day of admission (in-patient or observation). You should avoid billing for the service because the gastroen-terologist did not see the patient on the admission day. And inform the patient or his family that insurance may not cover the cost of the hospital care for the day before the procedure.

Some carriers may debate admitting a patient for observation status before the procedure as unnecessary medical care. The documentation should clearly and completely state the reasons that required the preprocedure in-hospital care.

Coding information for You Be the Coder and Reader Questions provided by Erica Folker, CPC, medical coding specialist for Mercy Health System in Janesville, Wis.; Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates; and Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.