Gastroenterology Coding Alert

Question: One of our patients presented for a screening colonoscopy, but during the visit the gastroenterologist decided the patient’s signs and symptoms proved they needed a diagnostic procedure rather than a screening. The doctor provided thorough notes to go along with the decision. Can I report the evaluation and management (E/M) portion of the visit?

Florida Subscriber

Answer: Typically, patients referred for a screening colonoscopy do not have signs or symptoms that point to needing a diagnostic procedure. The performing physician will sometimes want to see the patient prior to the screening, and that E/M is not separately billable. However, there are two exceptions, one of which is the situation you described.

You can report a separate E/M code when a patient presents for a screening colonoscopy and either of the following scenarios takes place:

• You’ve documented all the required E/M components, and based on the evaluation, the physician decides not to perform the procedure
• You’ve documented all the required E/M components, and the gastroenterologist determines that the patient’s signs and symptoms warrant a diagnostic colonoscopy instead of the screening colonoscopy (www.palmettogba.com/palmetto/jmb.nsf/DIDC/8EELDY5430~Preventive Services~Colorectal Cancer Screening)

In these situations, you will report the appropriate E/M code based on the documentation of time or medical decision making (MDM). If your provider’s documentation meets the requirement in the second option above, you’ll report the appropriate diagnostic colonoscopy code, such as 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), along with the E/M code.