Gastroenterology Coding Alert

Your gastroenterologist performs a service for a patient with hepatitis C that might qualify for the physician quality reporting initiative (PQRI). However, the patient refuses the proscribed PQRI treatment, saying they are forbidden by his religion.

What to do: Report the measure as you would have otherwise, with a modifier 2P (Performance measure exclusion modifier due to patient reasons) appended to the E/M code.

Why? Providers will receive credit for PQRI measures whether modified or not, confirms Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

Any time your gastroenterologist treats a patient that qualifies for PQRI, even if the described treatment isn't performed, it will count toward your PQRI total -- provided you list one of the following modifiers, depending on the situation:

• 1P" Performance measure exclusion modifier due to medical reasons;

• 2P;

• 3P-- Performance measure exclusion modifier due to system reasons; and

• 8P-- Performance measure reporting modifier -- action not performed, reason not otherwise specified.

Example: During a level-two E/M service for an established Medicare patient about to start antiviral therapy to treat his chronic hepatitis C, the gastroenterologist attempts to counsel the patient on using condoms during sexual activity. The patient cuts the gastroenterologist off, however, saying "My religion doesn't believe in that."

Even though this patient refused the counseling, this scenario is still eligible for PQRI measure 90 (Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy).

Report the claim as follows:

Numerator: 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) with 070.54 (Chronic hepatitis C without mention of hepatic coma) appended to represent the patient's condition.

Denominator: 4195F (Counseling regarding contraception received prior to initiation of antiviral treatment [HEP-C]) to represent the PQRI measure.

You can use the 8P modifier to receive credit for satisfactory reporting, but "will not receive credit for performance; use the 8P reporting modifier judiciously," warns Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla.

"The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice's quality improvement goals," she says.