Gastroenterology Coding Alert

Question: I have a claim with the following info: Established patient reports with vomiting and fever. The gastro orders a round of blood/stool tests, recommends some dietary changes and prescribes Prednisone for the condition. The encounter lasted 13 minutes. What E/M code should I use?

Kentucky Subscriber

Answer: There are three components that determine the E/M service level: history, exam and medical decision-making (MDM). When choosing an E/M code for an established patient, the gastroenterologist must satisfy two of these three components to qualify for a particular level of service. You-ll determine the correct code based on the documentation, regardless of the physician's performed work and time involved.

For example, an established patient with severe abdominal cramping in his left upper quadrant reports to the gastro. The gastro documents a level-one history and a level-two exam and provides level-two MDM. In this instance, you should throw out the history component because it is the lowest component and report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M service.

In your scenario, the gastroenterologist performed an expanded examination based on the chief complaint (level three) and provided low-complexity MDM (level three). On the claim, you should:

- report 99213 (... an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the office visit.

- attach ICD-9 codes 780.6 (Fever) and 787.03 (Vomiting alone) to 99213 to show the medical necessity for the E/M level.

Warning: Do not throw out the component with the lowest level of service when reporting E/M services for new patients. When a new patient presents, the gastroenterologist must satisfy all three components to code at a certain service level.

For example, if a new patient presented and the gastroenterologist performed a level-one history and a level-two exam and provided level-two MDM, you would report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision-making).