Gastroenterology Coding Alert

Learn how to justify those level-4 and -5 E/Ms your physician is performing.You already know that insurers scrutinize your practice's evaluation and management levels to see if you're coding more high-level E/Ms than the average gastroenterologist. Don't undercode out of fear of the auditor --" instead, get in the habit of good documentation to back up your practice's good patient service.Undercoding E/Ms is a long-standing problem. Back in 2003, the American Gastroenterological Association's GI Practice Management newsletter stated: "In our experience undercoding, billing a level of service lower than performed, is as prevalent in GI as overcoding. Often minor adjustments of the documentation will result in a higher level of service than what was billed."Evaluation and management of gastroenterology patients is complicated business. A thorough review of systems is an everyday thing for a gastroenterologist, so make sure good documentation of ROS is routine, too.Level-four and -five E/Ms are not that uncommon for a gastroenterologist's practice, so mastery of the doctor's review of systems is critical to backing up codes like 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history, a comprehensive examination, medical decision-making of moderate complexity ...).Know the ROS BasicsWhen your physician performs an E/M service, he conducts a review of systems (ROS) to check on the condition of the patient's body systems. For coding purposes, the level of ROS helps determine the level of patient history, which helps determine the level of E/M. If you do not know the level of ROS the physician performs, you will be unable to decide which level of E/M code you should use on the claim.To claim a level four or five E/M, documentation must indicate a comprehensive history. That requires an extended history of present illness; a complete past, family, and social history (PFSH); and a complete ROS.The basics: The main purpose of the ROS is to be sure no important symptoms have been missed, especially in areas not already covered in the HPI.The ROS is an interview in which the physician or nurse asks the patient about a specific system and records the patient's answers. Some physicians also get ROS information from patients through a questionnaire.CMS defines 14 systems for documentation:• Constitutional symptoms (such as weight loss)• Eyes (blurred vision)• Ears, nose, mouth, throat (trouble swallowing)• Cardiovascular (hypertension)• Respiratory (shortness of breath)• Gastrointestinal (nausea)• Genitourinary (urine incontinence)• Musculoskeletal (joint pain)• Integumentary (discolored skin)• Neurological (numbness)• Psychiatric (depression)• Endocrine (taking synthetic hormones)• Hematologic/lymphatic (anemia)• Allergic/immunologic (asthma/immunodeficiency).Tip: The physician can hand off the ROS work. "Your ancillary staff can document your review of systems and personal, family, social history," says Kim Garner-Huey, CPC, CCS-P, CHCC, an [...]