Gastroenterology Coding Alert

Question: The gastroenterologist saw a patient with GERD and started her on esomeprazole. The patient came back two weeks later and the nurse evaluated her, taking blood pressure and other vitals. She also asked the patient if she had experienced side effects since she started on the medication. The patient reported that she vomited several times immediately upon starting the medication, but that she felt fine since then. The nurse recorded that information in the record and advised the patient to stay on the medication and to alert the practice if the vomiting or any other side effects return. Is this a good candidate for 99213?

Codify Subscriber

Answer: Since you stated that the nurse performed the visit, it sounds more like this describes an appropriate billing of 99211, assuming the nurse documents the visit thoroughly. A patient who has just started a new medication regimen usually reports to the gastroenterologist by the latter’s order and is typically an established patient.

Although 99211 is often the best choice when a clinician performs a quick, medically necessary visit, it won’t always be paid. The Correct Coding Initiative (CCI) bundles 99211 into several other codes, and some payers maintain their own edits for it.

For instance, CGS Medicare says on its website, “Code 99211 is always bundled with injection administration procedures. CMS guidelines specify that the administration of injections is only paid separately when there is no other physician fee schedule service paid on that date of service for that provider.”

Do this: To avoid any payer queries, include this documentation on medication checkup E/Ms:

• A record of patient’s blood pressure, if relevant, and other vital signs
• A note indicating the clinical reason for checking blood pressure or other vital signs
• A list of the patient’s current medications (include level of patient compliance, if possible) proof that the gastroenterologist evaluated the clinical information the nurse obtained and made a management recommendation for the patient.