Gastroenterology Coding Alert

Question: In the examination room of our hospital, if our gastroenterologist performs a tube removal, should this be included in the E/M or should it be reported separately under a different code? Also, is it necessary for the hospital to report the E/M service separately?

Utah Subscriber

Answer: A tube removal performed should be included in the E/M only and need not be reported separately. The level of service for the E/M code will be determined by the documentation of the history, physicial examination, and medical decision making. In this case, the tube removal would be described within the E/M note.

The hospital will report the service based on the location of the examination room. If this is part of the ER then the hospital will report a facility service for the ER. If the examination room is part of the out-patient procedure unit then the hospital will report a facility service for an out-patient procedure.