Gastroenterology Coding Alert

Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicates that she spent 21 minutes advising the patient on proper diet and medication management. Is this an instance where I can code based on total encounter time?

New Jersey Subscriber

Answer: Maybe. Go back and double-check both the total encounter time and the amount of time the spent on counseling by either the physician or any nonphysician practitioner (NPP).

If the provider spends at least half (16 min) of the total session time counseling the patient, then report 99203 (Office or other outpatient visit for the evaluation and management of a new patient,  hich requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ... Physicians typically spend 30 minutes face-toface with the patient and/or family) for the encounter, based on the total time the provider spent face-to-face with the patient, with 531.70 (Gastric ulcer; chronic without mention of hemorrhage or perforation; without mention of obstruction) appended to represent the patient's condition.

Don't stop there: Whenever you invoke the counseling exception for E/Ms, be sure the patient's medical record has good documentation of the entire session.

For instance, a good note for your scenario might read: "Spent total of 34 minutes with patient. Talked about medication options and possible side effects for 15 minutes, and about diet and ulcer management for 6 minutes."

Remember: If you cannot enact the counseling exception for this encounter and code based on time, you must code based on the key elements. Choose the service level using the documented level of history, examination, and medical decision making the physician provides.

In your case, the visit's key components would qualify as 99202 (... an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...).

" 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.