Gastroenterology Coding Alert

Question: In your article last month on time-based E/M coding, you mentioned the factors that have to be in the documentation to bill this way. What about if the physician performs repeat counseling frequently for the same patient about the same topic? Our physician sees a patient with severe Crohn’s for a monthly checkup and really it’s just the GI answering her questions for about 30 minutes at a time. Can the physician write “Counseling similar to last visit” in the notes? That’s what he’s been doing and we’ve been getting paid.

Massachusetts subscriber

Answer: Documentation like you have described won’t work with most insurance auditors. Instead, you’d have to document what was discussed in each note. For instance, “Saw Jennifer Smith today to discuss possible dietary solutions to manage her Crohn’s disease. We spoke for 20 minutes of a total 25-minute visit and also talked about medication management options.”

A phrase like “counseling similar to last visit” sounds almost like the physician is cutting and pasting the same note from one visit to the next. In the electronic health record (EHR) guidelines, you are prohibited from simply using “cloned notes” like this in your documentation. Instead, each medical record entry should be unique to each visit.

You also mentioned that you’ve been documenting this way “and getting paid.” Although you’ve collected for your service, it’s likely that no one has reviewed the records for which you were paid. If you were ever audited, a note like that would not pass muster, and you’d probably have to return the money you collected for those services.