Gastroenterology Coding Alert

Question: A patient comes in for a consult because of abdominal pain and bloody diarrhea. The gastroenterologist performs the E/M service but then performs a sigmoidoscopy. Can I report both codes, and should I append modifier 25, even though the E/M service and the sigmoidoscopy were related?

Wyoming Subscriber

Answer: Yes, you can report both and include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Why: For any E/M service, you must link the service to a diagnosis that explains the reason the physician performed the service. But the E/M service needn't necessarily be "unrelated" to the other service or procedure the physician provides on the same day. CPT specifically states, "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date."
Report the whole picture: For your ICD-9 codes, report the primary signs-and-symptoms diagnoses of 789.0x (Abdominal pain) and 787.91 (Diarrhea NOS), which you'll link to the consult (for example, 99243, Office consultation for a new or established patient ...).

The gastro also performs a flexible sigmoidoscopy (45331, Sigmoidoscopy, flexible; with biopsy, single or multiple).
Because the abdominal pain and diarrhea prompted the flexible sigmoidoscopy, you may use the same diagnoses (789.0x and 787.91) to support the diagnostic procedure and the E/M service.
In this case, report 45331 for the sigmoidoscopy and add modifier 25 to the consult code (99243-25) to show that the E/M service was significant and separate from the diagnostic scope.

-- 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.