EM Coding Alert

Don’t forget to check for comorbid conditions.

Knowing how to navigate and select all of the codes necessary to report a pre-operative encounter takes a lot of knowledge. Boost your E/M service coding confidence, and remember that some ICD-10-CM knowledge is crucial, too.

Read more about the ins and outs of reporting a gastroenterology pre-op 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 pre-op 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 pre-colonoscopy 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.

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: You can read about global surgery guidelines at www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf.

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 pre-procedure 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 pre-op 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 pre-op 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).

Z codes also take the spotlight when a patient has no signs or symptoms, and the gastroenterologist performs a test solely for screening purposes. In this case, you should disregard typical diagnosis codes and locate an applicable Z code to describe the test to the payer.

Coding alert: Sometimes though, many non-Medicare payers recognize or prefer HCPCS code S0285 (Colonoscopy consultation performed prior to a screening colonoscopy procedure). Coverage is required for most commercial health plans but clarify with your payers if they prefer usual office/ outpatient codes or the S code for this service.