General Surgery Coding Alert

Don’t forget to check for comorbid conditions.

Knowing how to navigate and select all of the codes necessary to report a preoperative encounter takes a lot of effort. But in the process, you’ll boost your evaluation and management (E/M) service coding confidence and increase your ICD-10-CM understanding, too.

So, it will be worth your while reading on and learning more about the ins and outs of reporting a gastroenterology preop evaluation.

Focus on the Decision for Surgery

One common source of confusion has to do with separate E/M billing. For example, let’s say the surgeon sees a patient and schedules an operation based on that visit. When the patient comes back the day before the surgery for a preop evaluation, can you bill another E/M even if nothing has changed from that first encounter?

The answer may depend on the payer. For payers such as Medicare that have global surgery guidelines, you must bundle certain services before and after the surgery based on the rules for the appropriate global period.

So, under Medicare rules, once the provider makes the decision for surgery, you should not separately bill any preoperative visits related only to the surgery. In other words, the prescreening visits don’t usually present new information that warrant the need for an E/M service.

Exception: If the patient’s situation changes between the first and second visits before surgery, you might be able to make the case for billing another office/outpatient E/M.

For instance, if the patient develops a serious medical condition that is unrelated to the reason for the surgery, but could impact the outcome, the surgeon may perform additional services that increase the level of medical decision making (MDM) and, if properly documented, could allow you to bill a separate E/M visit. An example of this might be the sudden onset of severe symptoms of liver disease like jaundice, abdominal pain, and swelling during a precolonoscopy visit. This is a serious condition that could be considered unrelated to the need for a colonoscopy and would therefore require a completely separate E/M service.

Additionally, the provider could note “a significant progression of the condition, or a change in the indications for surgery that necessitate a new decision for surgery. The provider may be asking new questions, such as whether this is still the correct therapy or whether the risks of surgery still outweigh the benefit,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia,

Modifier alert: Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) when there is a separately billable E/M. Documentation must clearly support the separate service. “We need a robust paragraph of evaluation and management,” says Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

Learn More: Consult the Medicare Learning Network booklet, “Global Surgery.”

When Reporting Colonoscopies, Look for Comorbid Conditions

Providers often perform an E/M before screening colonoscopies, but these visits are generally not billable. However, there is an exception to this rule.

Physicians commonly do screening or surveillance colonoscopies for patients with serious comorbid conditions. They’ll perform medically necessary evaluations to assess whether the patient is stable enough to proceed and also to provide the patient with special instructions (such as how to manage anticoagulants, complex diabetic regimen, severe asthma, severe sleep apnea, etc.). In these situations, most Medicare contractors don’t question E/M visits before a colonoscopy.

If there are no apparent requirements for use of such specific codes, chart documentation should make clear the medical necessity for the preprocedure evaluation, even if the patient has no GI symptoms or disease. In other words, the ICD-10-CM codes in these situations should reflect the comorbid conditions, and the chart documentation should reflect the evaluation of the conditions as well as any special considerations. Such considerations might include management of insulin or diabetes meds, holding anticoagulants etc. Note that if you are reporting the screening Z code, do not submit it as the first code.

Report Z Codes First in Some Instances

Coders also sometimes have trouble understanding when to report a code from the Z00-Z13 block (Persons encountering health services for examinations) and how to sequence that code with other diagnosis codes.

If the chief reason for the encounter is a preop evaluation, you should first list a code from Z01.81- (Encounter for preprocedural examinations) to describe the evaluation. Then, you should assign a code for the condition that prompted the surgery as an additional diagnosis. Remember that any conditions discovered during the screening should be reported as additional diagnosis codes.

For example, let’s say that a patient who was scheduled for a gall bladder surgery presented for a preop evaluation. The physician listed the condition prompting the surgery as acute cholecystitis, which codes to K81.0 (Acute cholecystitis), and the underlying medical condition as diabetes, which you could document with a code such as E11.9 (Type 2 diabetes mellitus without complications). In this case, you’d first list Z01.818 (Encounter for other preprocedural examination) followed by the reason for surgery (cholecystitis) then the comorbidity (diabetes).