Gastroenterology Coding Alert

Follow-up visits with patients after an endoscopy or test are often billed as a low-level E/M service. Those visits, which may be dominated by a review of test results and counseling, usually don't require a significant level of history, examination or medical decision-making. If the time spent face-to-face with the patient is used as the key component, gastroenterologists may be able to bill for a higher level of E/M service for follow-up visits. It is important that gastroenterologists document the counseling portion as well as the E/M portion of the visit so the service will not be downcoded during an audit. 
Because gastrointestinal endoscopy procedures have a global period of zero days, a gastroenterologist can bill for a follow-up office visit on a subsequent day, says Joel Brill, MD, a gastroenterologist in Phoenix and the American Gastroenterology Association's representative to the CPT Editorial Advisory Committee. The visit will probably be an established patient office visit (99211-99215) because the patient has previously received professional services from the gastroenterologist. With procedures such as an esophageal motility study or 24-hour pH monitoring, where the physician or another provider may have performed the test, the gastroenterologist may still bill a follow-up visit when discussing the test results with the patient as long it meets the requirements of an E/M service. 
Two sets of E/M guidelines followed by both CPT and Medicare apply to follow-up visits. The first is that for an established patient office visit, two of the following three key components must be present during the encounter: history, examination and medical decision-making. The other guideline is that when counseling and coordination of care dominates more than 50 percent of the physician/patient encounter, time may be considered the key or controlling factor in choosing a particular level of E/M services rather than the level of history, examination and medical decision-making.   Key Components Must Always Be Documented   Even when time is the controlling factor, the three key components of an E/M visit --history, examination and medical decision-making -- must still be documented in the patient's medical record. Only two of the three components are needed for established patient office visits. 
"Even if the visit is primarily for counseling and coordination of care, you can't throw out history, examination and medical decision-making," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J. "You can't just write 'spent 35 minutes -- 20 minutes counseling patient' on the medical record. The auditor needs to know what you did for the other 15 minutes of the visit."
Brink recalls a chart she recently reviewed for a colonoscopy follow-up visit. The gastroenterologist's office had called the patient to say that [...]