Internal Medicine Coding Alert

Question: An established patient with a plan of care in place for her gastroesophageal reflux disease (GERD) reports to the internist. Two weeks ago, the internist started her on Nexium (esomeprazole).

Montana Subscriber

Answer: Coding will depend on the encounter specifics, but this service sounds like a 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services.)

No matter what E/M code you choose, be sure to include 530.81 (Other specified disorders of esophagus; esophageal reflux) to represent the patient's GERD and 787.03 (Vomiting alone) to represent the patient's persistent vomiting.

Explanation: The internist will often order a patient to report soon after starting a new medication regimen; these scheduled visits are typically 99211 encounters, though they can theoretically be higher-level if some complications arise.

For medication checkup encounters, insurers might want to see a clear explanation as to why the E/M was necessary. Cut off any payer queries by including the following information on medication checkup E/Ms:

• documentation clearly indicating the clinical reason for checking the patient's response to Nexium

• current medications listed (with notation of level of compliance)

• indication of the internist's evaluation of the clinical information obtained and her management recommendation

• substantiation of patient management by demonstrating medical decision-making, provision of patient education, etc.

• identity and credentials of provider(s).

If the NPP is a nurse practitioner or PA whose license allows her to provide services at a level above 99211, such documentation may support a higher level of service (e.g., 99212), especially if the NP or PA evaluates the clinical information and makes a management recommendation for the patient. This service may qualify for incident to if the physician was in the office at the time of this visit; otherwise, bill under the NPP's NPI number.

-- Answers to You Be the Coder and Reader Questions were reviewed by Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.