Gastroenterology Coding Alert

Question: When performing a comprehensive gastroenterology examination, which elements (bullets) should I count? Should I count HEENT?

Florida Subscriber

Answer: A single-organ "gastroenterology" examination does not exist. Gastroenterologists usually perform the general multisystem examination, which includes gastrointestinal (abdomen) as one of the organ systems/body areas covered. The other organ systems/body areas that are part of the multisystem examination include constitutional; eyes; ears, nose, mouth and throat; neck; respiratory; cardiovascular; chest (breasts); genitourinary; lymphatic; musculoskeletal; skin; neurologic; and psychiatric.

To meet the definition of a comprehensive examination, gastroenterologists have to examine and document findings from several organ systems/body areas -- not just the gastrointestinal. The 1997 E/M documentation guidelines adopted by Medicare and the AMA state that a comprehensive examination should include at least nine organ systems or body areas. Your payers will expect documentation of at least two elements identified by a bullet in each area or system. Gastroenterologists may also follow the less-specific 1995 E/M guidelines, which state that a comprehensive examination is a complete general multisystem examination.
 

 You can count head, ears, eyes, nose and throat (HEENT) as part of the exam. For documentation, your physician needs to list each component separately. If your MD states, "HEENT was normal," it counts as one element. If your MD states, "Head is normal, ears are normal, eyes are normal, nose is normal, and throat is normal," the note counts as five elements.