Gastroenterology Coding Alert

Question: Our gastroenterologist sees a patient on rounds in the morning. The hospital staff calls the physician back to the hospital in the evening to re-examine the patient. Should I treat the second visit as bundled to the first?


Iowa Subscriber

Answer: You can code for your physician's effort, but remember that the hospital initial and subsequent visits are -per day,- not -per visit.-

What to do: Combine the work from the second visit with the work from the first encounter. Choose an E/M code that represents the work and documentation performed in both visits. Although you should report only one E/M code for the day's service, CPT and CMS do not restrict you to payment for one visit per day.

Example: In the morning, the gastroenterologist performs a subsequent hospital visit for a clinically stable patient. He performs and documents a problem-focused interval history, a problem-focused examination, and straightforward medical decision-making.

Later that day, the patient has severe heartburn and stomach pains, and a staff member requests that the gastroenterologist re-evaluate his condition. The physician performs and documents an expanded problem-focused interval history, an expanded problem-focused exam, and moderate-complexity medical decision-making.

The gastroenterologist should elect a single code that covers the E/M elements from both the morning and the evening visits. Don't -double-dip- the E/M components. So, if the HPI contains the same elements (such as location, duration and severity) in both visits, you can only count them once.

Tip: Check whether the time involved in the extra visit warrants prolonged services. For more than 30 minutes face-to-face with the patient beyond the time indicated for the chosen service level, assign prolonged inpatient physician services with +99356 (Prolonged physician service ...) and +99357 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]). Be certain the doctor documents the time spent providing face-to-face care in the progress note.