Gastroenterology Coding Alert

Question: The general surgeon has asked us to determine whether one of our established patients, a 68-year-old male with stenosis, is able to withstand the general anesthesia required to remove a cancerous colon tumor. Can it be billed separately or is it bundled as part of the procedure?

Arizona Subscriber

Answer: Yes. On some occasions an EKG must be performed prior to an EGD/colonoscopy. You can bill for gastro-intenstinal pre-operative evaluations using the appropriate CPT® code (new patient, established patient). Pre-operative evaluations often qualify as consultative visits. You can bill a consultation if a surgeon asks you to evaluate a patient’s fitness for colon surgery—even for one of your established patients—if you meet the following criteria:

• offer an opinion or advice to the requesting physician and document your opinion;
• make a treatment options decision;
• perform or order distinctive diagnostic or therapeutic procedures and document them; and

send a written report detailing your opinion and any diagnostic/therapeutic services to the requesting physician.

Your GI will evaluate the patient in your office, performing a history and physical examination, and pay special attention to his cardiovascular system because he has a history of aortic stenosis. The GI should also order and perform a routine electrocardiogram (ECG) and send a written report detailing the findings, including recommendations regarding antibiotic prophylaxis, to the operating surgeon.

Medicare requires that you justify pre-operative visits and tests using a diagnosis code that indicates the type of preventive examination and the condition(s) that prompted the surgery. You should report primary diagnosis ICD-9 code V72.81 (Pre-operative cardiovascular examination) to justify the ECG and appropriate E/M code. Use CPT® code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). 

List the ICD-9 code indicating the reason for the surgery as the secondary diagnosis. Include on the claim additional diagnoses (or other information) relevant to the pre-operative service(s). In your case, you should report ICD-9 code 153.9 (Malignant neoplasm of colon unspecified site) for colon cancer to explain the reason for the surgery. Use 424.1 (Aortic valve disorders) for the complication in surgery, as supporting justification.