EM Coding Alert

Either time or medical decision making may be used if visit counts as an E/M service.

Some coders may feel like they need more help in determining whether to report an evaluation and management (E/M) code for an encounter including a screening colonoscopy service.

Pocket this primer to make sure you stay on the right side of colonoscopy reporting.

Perform an Audit on Visit Notes

If your provider frequently tacks an E/M code (99202-99215) on to their screening colonoscopy service claims, then chances are you haven’t audited your claims in a while. However, any practice auditing its claims would notice that the documentation may not support the depth of medical decision making or medical necessity necessary to report an E/M code.

For example, suppose your physician reported 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter) with nine out of their last 10 screening colonoscopies (e.g., G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Ask this: When reviewing the documentation, ask yourself what the chief complaint is for the E/M visit. A patient presenting solely for the purpose of a screening colonoscopy would likely not have a chief complaint to report. In fact, you’re unlikely to find any justification for the visit other than what the physician might convey to the patient on the day of the procedure. Therefore, it’s clear that the documentation does not meet the medical necessity required of an E/M service.

Check In on Medicare Rules

If your provider persists in reporting E/M codes with screening colonoscopies, offer them the language from the Centers for Medicare & Medicaid Services (CMS) or your local Medicare Administrative Contractor (MAC).

For example, Part B MAC Palmetto GBA updated its article on this topic on Dec. 11, 2020. In its directive, Palmetto notes: “The physician performing the colonoscopy may wish to see and evaluate the patient prior to the screening colonoscopy. In this case, the evaluation and management (E/M) visit is generally not separately billable.”

Even in patients deemed high risk, the reimbursement for the appropriate high-risk screening code (such as G0105, Colorectal cancer screening; colonoscopy on individual at high risk) already includes the pre-service work associated with a screening colonoscopy in a high-risk patient, Palmetto advises.

Report the E/M Code in These Situations

Although you are typically out of luck when reporting a separate E/M for patients who present for screening colonoscopies, there are a few exceptions, according to the Medicare rules. You can report a separate E/M code when patients present for a screening colonoscopy and either of the following scenarios takes place, Palmetto says:

• You’ve documented all the required E/M components, and based on the evaluation, the physician decides not to perform the procedure
• You’ve documented all the required E/M components, and the gastroenterologist determines that the patient’s signs and symptoms warrant a diagnostic colonoscopy instead of the screening colonoscopy

In these situations, you will report the appropriate E/M code based on the documentation of time or medical decision making. If your documentation meets the requirement in the second option above, you’ll report the appropriate diagnostic colonoscopy code (such as 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), along with the E/M code.

In the event the E/M service is performed on the same day as the procedure, 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) to the E/M code since the National Correct Coding Initiative (NCCI) bundles the E/M codes into the diagnostic colonoscopy codes or any same-day endoscopic procedure. Since gastrointestinal (GI) endoscopic services are “zero-day global” services, E/M services performed on a different date do not require a modifier.

Resource: To read Palmetto’s complete document on this topic, visit the Palmetto website.

Don’t Forget These Possible Exceptions

Physicians commonly perform screening or surveillance colonoscopies for patients with serious comorbid conditions and perform medically necessary visits for assessment (to determine whether the patient is stable enough to proceed) and for 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.