Understand Carrier Policy on E/M with Open Endoscopy
Published on Wed Nov 01, 2000
While there are situations where it is appropriate to bill an evaluation and management (E/M) service on the same day as an endoscopic procedure, gastroenterologists and coders should be cautious about reporting a standard preoperative consultation with the patient on the same day as an open-access procedure. Medicare considers preoperative evaluations to be incidental to the endoscopic procedure and not separately payable. In addition, gastroenterologists should fulfill all the requirements of a consultation before reporting that type of E/M service.
Pre-Op Visit Incidental to Open Access Procedure
It is not unusual for primary-care physicians and other providers to directly schedule a patient for an endoscopic procedure without a prior evaluation by the gastroenterologist who will be performing the endoscopy. This type of arrangement is often referred to as an open-access procedure or endoscopy on demand.
On the day of the procedure, most gastroenterologists will perform a preoperative evaluation of the patient to determine whether the patient can be safely sedated or whether there are any risk factors that need to be monitored, according to Pat Stout, CMC, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn.
That preoperative E/M service is considered by Medicare to be incidental to the procedure and not separately billable. Section 4821(C) of the Medicare Carriers Manual (MCM) states that [v]isits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.
To bill for an E/M service on the same day as an endoscopy, the service must be rendered for a significant, separate reason, says Faith Marie Hope, CPC, CCS-P, a member of the AAPC National Advisory Board, and a senior compliance consultant at Shared Medical, a healthcare consulting firm in Malvern, Pa.
Report E/M Service with a Separate Diagnosis
An example of a significant, separately identifiable service is when a patient comes in for a screening colonoscopy, but describes an acid reflux problem to the gastroenterologist during their initial encounter, says Hope.
The gastroenterologist will then ask questions about the patients history with these acid reflux symptoms, perform an examination and perhaps put the patient on a prescription to treat the acid reflux condition, she explains. The gastroenterologist will have two diagnosis codes to report: one for the family history of colon cancer (V16.0) and the other for acid reflux (530.81). The gastroenterologist can bill for a separate E/M service, attaching modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code and a related diagnosis code.
If audited by Medicare, the gastroenterologist will have [...]
