Gastroenterology Coding Alert

Question: An established patient with a plan of care in place for her gastroesophageal reflux disease (GERD) reports to the gastroenterologist; two weeks ago, the gastroenterologist started her on Nexium (esomeprazole).

Minnesota Subscriber

Answer: Coding will depend on the encounter specifics, but this sounds 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.

No matter what E/M code you choose, append the following diagnosis codes:

• 530.81 (Other specified disorders of esophagus; esophageal reflux) to represent the patient's GERD

• 787.03 (Vomiting alone) to represent the patient's persistent vomiting.

Explanation: The gastroenterologist will often order a patient to report soon after starting a new medication regimen; these scheduled visits are typically 99211 encounters, though theoretically they can be higher-level if complications arise.

For medication checkup encounters, insurers might want to see a clear explanation as to why the E/M was necessary. Cut off any payer queries by including the following 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.