Gastroenterology Coding Alert

Answer: Sometimes a gastroenterologist will need to do a consultation in the hospital and schedule a procedure for the same day. In cases like this, the procedure and the consult (99251-99255) should both be reimbursed. The key to reimbursement is using modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the consult.

For example, the gastroenterologist is called in for a consultation on a patient complaining of nausea, abdominal pains, and blood in the stool. He takes a detailed history and examination and performs medical decision-making of low complexity. The physician determines the need to perform a colonoscopy to further diagnose the patient's problem. You would report the level-three initial inpatient consultation code 99253-25 and 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]).

You are correct in that you should report symptoms for the consultation, such as 787.02 (Nausea), 789.0x (Abdominal pain), and 578.1 (Blood in stool). You should also report the findings of the diagnostic procedure, if available. When any procedure or test results are normal or do not allow the physician to make a diagnosis, you should code only the signs and symptoms with which the patient presented. Do not code diagnoses that are not confirmed. ICD-9 coding guidelines forbid the coding of unconfirmed diagnoses that are listed as probable, suspected, questionable or rule-out.

In the best scenario, it would be nice to have a separate diagnosis code from the procedure. According to Linda Parks, MA, CPC, CCP, coding specialist at GI Diagnostics Endoscopy Center in Marietta, Ga., you would prefer to have separate codes because it shows that the visit is separate and identifiable. However, this is not always the case when you have to do a consultation in order to decide to do the other procedure. If a gastroen-terologist sees a patient for a gastrointestinal bleed and subsequently performs a colonoscopy, the GI bleed is the only code you will have. You do not have to attach any separate documentation. Parks finds that 99 percent of the time it will be paid. As long as you have the procedural operative note and E/M documentation, you should be safe.