Gastroenterology Coding Alert

Question: When performing a comprehensive gastroenterology examination, which elements (bullets) should I count? Should I count HEENT?

Florida Subscriber
 
Answer: There is no single-organ "gastroenterology" examination, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT Advisory Panel. Gastroenterologists usually perform the general multisystem examination, which includes gastrointestinal (abdomen) as one of the organ systems/body areas covered. The other organ systems/body areas that are part of the multisystem examination include constitutional; eyes; ears, nose, mouth and throat; neck; respiratory; cardiovascular; chest (breasts); genitourinary; lymphatic; musculoskeletal; skin; neurologic; and psychiatric.
 
To meet the definition of a comprehensive examination, gastroenterologists have to examine and document findings from several organ systems/body areas not just the gastrointestinal. The 1997 E/M documentation guidelines adopted by Medicare and CPT state that a comprehensive examination should include at least nine organ systems or body areas. Documentation of at least two elements identified by a bullet in each area or system is expected. Until updated E/M guidelines are issued, gastroenterologists may follow the less-specific 1995 E/M guidelines, which state that a comprehensive examination is a complete general multisystem examination.
 
Head, ears, eyes, nose and throat (HEENT) can be counted as part of the exam. For documentation, you should list each component separately. "If you state, 'HEENT' was normal, it counts as one element," Weinstein says. "If you state, 'Head is normal, ears are normal, eyes are normal, nose is normal and throat is normal,' then that counts as five elements."
 
To learn more on E/M documentation guidelines, visit the Medicare Learning Network at www.hcfa.gov/medlearn/emdoc.htm.