Gastroenterology Coding Alert

Question: What E/M code should I code for the following scenario: This established patient is an 85-year-old white female who presented to the GI lab for evaluation of a GJ tube. She recently had a GJ tube replaced by doctor. According to the husband, the tube initially worked but has not worked over the last couple of days.

He went to the ER and they put Coke through her J tube, but this was somewhat sluggish. The gastroenterologist was able to inject through the J tube. There was some mild resistance, but it passed with gentle pressure. The gastro wondered if the tube could have a small kink, which has happened before. The gastro elected not to do an endoscopy given the risks, but to have a radiologic GJ tube evaluation.

Tennessee Subscriber

Answer: In this scenario, you don't describe an exam and what documentation your physician completed.

Because the patient is established, you would probably use 99212 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 10 minutes face-to-face with the patient and/or family). This of course depends on your documentation. History and medical decision-making (MDM) are adequate for an established E/M code.

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.