Gastroenterology Coding Alert

Question: The gastroenterologist sees an established patient with a plan of care in place for her gastroesophageal reflux disease (GERD). Two weeks ago, the gastroenterologist started her on Nexium (esomeprazole). During the visit, one of our nonphysician practitioners (NPPs) evaluates the patient, taking blood pressure and other vitals. She also asks the patient if she has experienced side effects since she started Nexium. The patient reports that she has "thrown up three or four times" since starting Nexium. The gastroenterologist's report indicates that the visit is specifically for checking how the patient is adjusting to the medication. What E/M code should I report for this encounter?

Georgia Subscriber

Answer: This looks like a 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services ...) service. Regardless of the E/M code you use, don't forget to append the following diagnosis codes:

• 530.81 (Other specified disorders of esophagus; esophageal reflux) for the patient's GERD
• 787.03 (Vomiting alone) for the patient's vomiting.

Key: A patient who has just started a new medication regimen usually reports to the gastroenterologist by the latter's order.

These scheduled visits are usually 99211 encounters, but could be higher-level if complications arise.

Do this: To avoid any payer queries, include this documentation on medication checkup E/Ms:

• a record of patient's blood pressure, if relevant, and other vital signs
• a note indicating the clinical reason for checking blood pressure or other vital signs
• a list of the patient's current medications (include level of patient compliance, if possible) proof that the gastroenterologist evaluated the clinical information the NPP obtained and made a management recommendation for the patient.