Gastroenterology Coding Alert

Question: We have a new gastroenterologist in our practice and he wants to see the patients (that are coming for a screening colonoscopy) prior to performing the procedure which he will schedule for later. Can I charge for this visit? He is of the opinion that the preliminary visit can be charged but I am not too sure whether this is right.

Maryland Subscriber

Answer: Any routine pre-procedure evaluation and management service that is provided immediately (same day) before your gastroenterologist undertakes a screening colonoscopy will not be paid for by Medicare and will usually be denied by commercial carriers. If the patient seeks an appointment prior to scheduling a screening colonoscopy or is referred to by another physician requesting a screening colonoscopy, you may not want to bill any E/M codes for the encounter. This policy of a bundled routine E/M visit is specifically defined by Medicare, and some other commercial carriers are following this.

You can only bill for an E/M visit prior to a screening colonoscopy if the services provided for the evaluation and management is significantly and separately identifiable. So you can bill for an E/M visit prior to a screening colonoscopy if the purpose of the encounter was for a totally different reason not in any way related to the screening colonoscopy procedure. The diagnosis code for the E/M visit should reflect the patient's medical condition or symptoms rather than the diagnosis code for colorectal cancer screening (V76.51, Special screening for malignant neoplasms colon).

If the evaluation and management is for an unrelated reason, you can use the appropriate E/M codes for the visit. If the visit is on the same day as the procedure then don't forget to append the 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 that you are reporting for the visit to enable reimbursement without denial for your claim.