Gastroenterology Coding Alert

You may have to perform a quick review of the claim to make sure.

GI physicians perform colonoscopies often enough that they may have the codes committed to memory, but many coders are still unclear about when it’s acceptable to report an E/M visit the same day as a screening colonoscopy service.

Check out a quick primer that can help you evaluate when you can report an E/M service with a colonoscopy, and when you should skip it.

First, Audit Your Visit Notes

If your gastroenterologist frequently tacks an E/M code (99202-99215) on to their screening colonoscopy service claims, then chances are you haven’t audited your claims in a while. Although this may sound like an unusual supposition, the reality is that any practice auditing its endoscopists’ claims would immediately notice that the documentation is almost certainly lacking the medical decision making and medical necessity required to report an E/M code.

For example, suppose your physician reported 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter) with nine out of their last 10 screening colonoscopies (e.g., G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Ask this: When reviewing the documentation, ask yourself what the chief complaint is for the E/M visit. A patient presenting solely for the purpose of a screening colonoscopy would likely not have a chief complaint to report. In fact, you’re unlikely to find any justification for the visit other than what the physician might convey to the patient on the day of the procedure. Therefore, it’s clear that the documentation does not meet the medical necessity required of an E/M service.

Check What Medicare Says

If your gastroenterologist persists in reporting E/M codes with screening colonoscopies, offer them the language from CMS or your local Medicare Administrative Contractor (MAC).

For example, Part B MAC Palmetto GBA updated its article on this topic on Dec. 11, 2020. In its directive, Palmetto notes, “The physician performing the colonoscopy may wish to see and evaluate the patient prior to the screening colonoscopy. In this case, the evaluation and management (E/M) visit is generally not separately billable.”

Even in patients deemed high-risk, the reimbursement for the appropriate high-risk screening code (such as G0105, Colorectal cancer screening; colonoscopy on individual at high risk) already includes the pre-service work associated with a screening colonoscopy in a high-risk patient, Palmetto advises.

Here’s When You Can Report the E/M

Although you are typically out of luck when reporting a separate E/M for patients who present for screening colonoscopies, there are a few exceptions, according to the Medicare rules. You can report a separate E/M code when patients present for a screening colonoscopy and either of the following scenarios takes place, Palmetto says:

• You’ve documented all the required E/M components, and based on the evaluation, the physician decides not to perform the procedure
• You’ve documented all the required E/M components, and the gastroenter­ologist determines that the patient’s signs and symptoms warrant a diagnostic colonoscopy instead of the screening colonoscopy

In these situations, you will report the appropriate E/M code based on the documentation of time or medical decision making. If your documentation meets the requirement in the second option above, you’ll report the appropriate diagnostic colonoscopy code (such as 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), along with the E/M code.

In the event the E/M service is performed on the same day as the procedure, 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) to the E/M code since the National Correct Coding Initiative (NCCI) bundles the E/M codes into the diagnostic colonoscopy codes or any same-day endoscopic procedure. Since GI endoscopic services are “zero-day global” services, E/M services performed on a different date does not require a modifier.

Resource: To read Palmetto’s complete document on this topic, visit the Palmetto website.

What About Conditions Requiring Special Consideration Before Colonoscopy?

Physicians commonly do screening or surveillance colonoscopies for patients with serious comorbid conditions, and perform medically necessary visits to provide for assessment (to determine whether the patient is stable enough to proceed) and for 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.

In such cases, the ICD-10-CM coding should first list the medical condition that the gastroenterologist assesses and counsels. Payer policies differ regionally on whether to use the screening or surveillance codes for the exam (such as Z10.11 for screening, Z86.010 for polyp history, etc.), or the code for a pre-op evaluation, such as Z01.810 (Encounter for preprocedural cardiovascular examination-e.g. history anticoagulation needing management) or Z01.818 (Encounter for other preprocedural examination). If the reason relates to morbid obesity, code any comorbidities such as sleep apnea, or at least the ICD-10-CM code for the patient’s BMI.

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.

What About Non-Medicare Payers?

Although not widely publicized, the Department of Labor published requirements for commercial plans that are compliant with Affordable Care Act regulations (meaning non-grandfathered, employee-sponsored plans; in other words, most currently available commercial plans). The requirements state that payers must allow for a pre-screening colonoscopy visit, without deductible or copay, and also allow for colon prep materials and for pathology without deductible or copay when screening becomes therapeutic. Some private plans may publish policy related to how to report these services (E/M visit codes versus preventive care visit codes) or restrict the billable level of service.

“Some of the Blue Cross/Blue Shield plans plan accept, or require, a HCPCS S code,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. “S0285 (Colonoscopy consultation performed prior to a screening colonoscopy procedure) is a valid HCPCS code for 2022,” he said.