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Gastroenterology Coding Alert

Reader Questions:

2 Out of 3 Ain't Bad - for Established Patient E/M Services

Published on Sat Jan 01, 2005

Question: I have a claim sitting in front of me with the following info: Established patient reports with vomiting and fever. The gastro orders a round of blood/stool tests, recommends some dietary changes and prescribes Prednisone for the condition. The encounter lasted 13 minutes. What E/M code should I use?

Minnesota Subscriber

Answer: There are three components that determine level of service on E/M encounters: history, exam, and medical decision making (MDM). When choosing an E/M code for an established patient, the gastro must satisfy two of these three components to qualify for a particular level of service. The correct code will be determined by the documentation, regardless of the physician's performed work and time involved.

For example, let's say an established patient reports to the gastro with severe abdominal cramping in his left upper quadrant. The gastro documents a level 1 history, a level 2 exam and provided level 2 medical decision making. In this instance, you should throw out the history component and:
 

  •  report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components; a problem focused history; a problem focused examination; straightforward medical decision making) for the E/M service.
     
    In your scenario, the gastro performed an expanded examination based on the chief complaint (level 3) and provided low-complexity MDM (level 3). On the claim, you should:
     
  •  report 99213 ( ...an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity) for the office visit.
     
  •  attach ICD-9 codes 780.6 (Fever) and 787.03 (Vomiting alone) to 99213 to show the medical necessity for the E/M level.
     
    Warning: Do not throw out the component with the lowest level of service when reporting E/M services for new patients. When a new patient presents, the gastro must satisfy all three components to code at a certain level of service.

    For example, if a new patient presented and the gastro performed a level 1 history, a level 2 exam and provided level 2 MDM, you would:
     
  •  report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:a problem focused history; a problem focused examination; and straightforward medical decision making).

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