Gastroenterology Coding Alert

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 to be able to support his or her claim that the separately billed E/M service was clearly significant and separate from the endoscopic procedure. Documentation takes a front seat here, says Hope, adding that gastroenterologists can support their claims by including the following information in their documentation when appropriate:

different diagnosis codes for the E/M service and the endoscopic procedure;
different examination elements that correlate to the patients various complaints; and
a treatment plan, such as the ordering of medication or a different endoscopic procedure that specifically addresses the patients other complaint.

An E/M service cannot be billed, however, if the gastroenterologists treatment plan consists of scheduling another appointment to further evaluate the second complaint. Physicians should render some sort of medical decision-making in order to bill for an E/M service, Hope explains. You just cant tell the patient to come back for another visit.

Carriers Vary on Reimbursing for E/M Service

When an E/M service leads to the decision to perform the endoscopy on the same day as the procedure, Medicare carriers vary on whether they will reimburse for the E/M service. This includes emergency situations such as when the patient comes to either the emergency room or the gastroenterologists office with urgent symptoms such as rectal bleeding or severe abdominal pain and the gastroenterologist decides that an endoscopy must be performed immediately.

The MCM gives conflicting instructions on this issue. Section 4128 (B) states that it will pay for an E/M service on the same day as a procedure when it is the initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.

Section 4822 (A.4), however, seems to instruct carriers not to pay for these E/M services when an endoscopy is involved. Because Medicare usually classifies endoscopies as minor surgery, many carriers look at this section for guidance when it comes to gastroenterology procedures. This section states [w]here the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.

The end result is that a carrier may not reimburse for an E/M service that led to the decision to perform an endoscopy and was reported on the same day as the procedure. The Texas carrier, Trailblazers Healthcare Enterprises, is one that will reimburse for the service. It announced in its Medicare Part B Newsletter dated March 1, 1999, that the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. Thus, different diagnoses are not required for reporting the E/M services on a different date.

Empire Medicare Services, the Medicare carrier for New York and New Jersey, also has announced that it will pay for such an E/M service. The New York and New Jersey Medicare News Brief of September 1999 instructs providers to use modifier -25 when performing a separately identifiable evaluation and management (E/M) service on the same day you perform minor surgery. Use the -25 modifier if a minor surgical procedure was decided upon at the time of the visit. Add the modifier to the visit code.

Not all carriers are as clear in their instructions and have not addressed this issue in their local Medicare bulletin or newsletter. Gastroenterologists with questions on the reporting and reimbursement of E/M services that led to the decision to perform an endoscopy and were reported on the same day as the procedure should check with their local Medicare carrier for specific instructions and guidance.

Consultation or New Patient Visit?

In situations where it is appropriate to bill a separate E/M service, gastroenterologists should look carefully at what type of E/M visit is applicable. While many gastroenterologists will commonly bill for an office or outpatient consultation (99214-99245), both Stout and Hope say that a new patient code (99201-99205) is often more appropriate.

To qualify as a consultation, an E/M service must fulfill three requirements, which are frequently referred to by coding experts as the three Rs:

1. Request: The referring physician must make a request in writing to the gastroenterologist, soliciting his or her opinion on the patients condition. This request should also explain why the consultation is being requested.

2. Review: The gastroenterologist must review the patients condition. The documentation in the patients medical record should indicate the history taking, examination and medical decision-making performed by the gastroenterologist. All three of these key components of an E/M visit (history, examination and medical decision-making) must be considered to determine the level of consultation.

3. Report: After the review of the patients condition, the gastroenterologist must issue a written report back to the referring physician on the patients condition. A copy of the report should be filed in the patients medical record.

In the case of the patient who is having a colonoscopy and reports symptoms of acid reflux, a consultation can be billed only if the primary-care physician mentions acid reflux on his or her request to the gastroenterologist, Hope says. Then a written report must be sent back to the referring physician from the gastroenterologist.

Stout believes that gastroenterologists often confuse the request to perform an endoscopic procedure with a request for an E/M consultation. The gastroenterologist has to understand the exact wording of the referring physicians request, she says. If this is an open-access procedure, then the physician is requesting a procedure, not an E/M service. The key words here are advice and opinion. If the patient is sent over strictly for a procedure, then advice and opinions are not being requested.

If it is appropriate to bill an E/M service on the same day as an endoscopy, but the service rendered does not qualify as a consultation, it is advised to bill it as a new patient office/outpatient code, according to both Stout and Hope. The level of visit to be billed will still depend on all three key components of an E/M service as it does with a consultation. But a new patient visit does not require a request from a referring physician or a report from the gastroenterologist to the referring physician.

Using Modifiers for Global Periods

Modifier -25 should be attached to any E/M service reported on the same day as an endoscopic procedure or any procedure with a global period of less than 90 days, according to Stout.

Note: The global or postoperative period for a procedure can be found in the Medicare Physicians Fee Schedule database, which is available at the Health Care Financing Administration (HCFA) Web site at www.hcfa.gov. For procedures with zero global days, the global surgical period includes the day of the procedure, but zero days after the procedure.

Many subscribers of Gastroenterology Coding Alert have reported being told at recent conferences with their local Medicare representative to attach modifier -57 (decision for surgery) to the E/M visit instead of modifier -25. These conferences are probably not tailored for gastroenterology practices, says Stout. The MCM states that modifier -57 is used to report an E/M visit with surgical procedures that have a global period of 90 days. Because most endoscopic procedures have a global period of zero days, however, gastroenterologists should be using modifier -25 most of the time.

Specifically, Section 4821 of the MCM states that codes with zero or 10 day global periods are considered either minor surgical procedures or endoscopies. Codes with 90-day global periods are considered major surgery. Section 4822 (A.4) also states that modifier -57 is not used with minor surgeries.

CPT Guidelines Differ From Medicare

Another reason for the coding confusion between modifier -25 and -57 is that the CPT definition of modifier -25 states that [t]his modifier is not used to report an E/M service that resulted in a decision to perform surgery.

This is one instance where Medicare policy and CPT guidelines differ. In the past few years, the confusion over whether to use modifier -25 or -57 has caused several state Medicare carriers to issue clarifications such as the previously cited example from the New York and New Jersey Medicare bulletin that instructs providers to use modifier -25.

Some local Medicare carriers, such as Californias National Heritage Insurance Company, may not require modifier -25 when reporting an E/M service provided to a new patient. The December 1998 issue of the California Medicare Bulletin informs providers that [a] new patient E/M service is considered separate from a same day procedure, when documentation guidelines are met. Therefore, modifier -25 does not need to be attached to E/M services that are strictly for new patients, such as 99201-99205 (new patient office or other outpatient visit), and are performed on the same day as a surgery or procedure.

Finally, E/M services performed with a screening colonoscopy or flexible sigmoidoscopy for a Medicare patient cannot be billed even when the E/M service is performed several days or even weeks before the procedure has been scheduled. Stout notes that the national Correct Coding Initiative bundles all E/M services into HCPCS code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) and the E/M services are not separately payable even when performed on a different day than the procedure.