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Gastroenterology Coding Alert

Consider Dates of Service Before Filing Discharge Claim

Published on Sun Aug 07, 2005

Discharge is bundled into most observation codes

If your gastroenterologist performs a procedure in a hospital and then keeps the patient for observation, the hospital evaluation and management (E/M) codes you report will depend on the length of patient stay. Sometimes, you can report the discharge separately from the admission.

The basics: In most instances, you can report only one E/M service a day, so you cannot bill for the hospital discharge if it happened the same day as the hospital admit, says Cindy Parman, CPC, CPC-H, RCC, president of the AAPC National Advisory Board and co-owner of Coding Strategies Inc. in Dallas, Ga.

2 Code Sets Represent Same-Day Discharge

If your gastroenterologist performs the procedure on the patient, evaluates him and discharges him on the same calendar day, you should report only the procedure code and one observation code, Parman says. Before deciding on the code set to use, determine how long the patient stayed in observation.

If the patient is admitted for fewer than eight hours and is then discharged on the same day, you should select a code from the 99218-99220 group to report the admission.

Example: A patient reports to the hospital for an endoscopic retrograde cholangiopancreatography (ERCP). During the procedure, the gastroenterologist also uses the endoscope to remove calculi from the pancreatic ducts. 

After the procedure, the patient is hypotensive and complaining of pain. The patient is admitted to observation at 10 a.m., after the gastroenterologist performs the ERCP, and has the patient discharged at 5 that afternoon when further evaluation shows the patient to be improved and stable. During the patient's stay, the physician provides level-two observation service.

In this instance, you should:
 

  •  report 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts) for the ERCP.
     
  •  report 99219 (Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the hospital E/M services.
     
  •  attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99219 to show that it was a separate service from the ERCP.

    However, when a patient is admitted to observation or inpatient hospital care for more than eight hours and is then discharged on the same day, report a code from the 99234-99236 family.

    Example: A patient reports for an ERCP with pressure measurement of the sphincter. He is admitted at 8 a.m. after the gastroenterologist performs the ERCP, and discharges the patient at 10 that night. During the patient's stay, the gastroenterologist provides level-two observation service.

    In this instance, you should: 

  •  report 43263 (Endoscopic retrograde cholangiopancreatography [ERCP]; with pressure measurement of sphincter of Oddi [pancreatic duct or common bile duct]) for the ERCP.
     
  •  report 99235 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the hospital E/M services.
     
  •  attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99235 to show that it was a separate service from the ERCP.

    If the patient has to be kept overnight for observation and then discharged the next day, the coding guidelines change for the E/M services.

    For the day of admission, you would report a code from the 99218-99220 group, and for the day of discharge, you'd use 99217, Parman says.

    Example: A patient reports to the hospital for a colonoscopy with ultrasound and fine needle aspiration. He is admitted at 11 a.m. after the gastroenterologist performs the colonoscopy because of a concern about postprocedure perforation. He discharges the patient at 9 the next morning. During the patient's stay, the gastroenterologist provides level-three E/M service, and the discharge service takes 20 minutes.

    In this instance, you should:
     

  •  report 45392 (Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]) for the colonoscopy.
     
  •  report 99220 (Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the observation services.
     
  •  attach modifier 25 to 99220 to show that it was a separate service from 45392.
     
  •  report 99217 (Observation care discharge day management) for the discharge service.

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