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Gastroenterology Coding Alert

READER QUESTIONS:

Use Modifier 25 on E/M With Procedure Claim

Published on Sun Aug 07, 2005

Question: A patient with esophagitis reported for a scheduled esophagoscopy with biopsy. On her registration form, the patient also reported having severe, generalized stomach pain and bouts of vomiting in the past week. The gastroenterologist performed the esophagoscopy, and then provided level-two evaluation and management service for the stomach pain and vomiting. How should I report the encounter?


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Answer: If your claim proves that the gastroenterologist performed the esophagoscopy with biopsy, then lent separate time and expertise to the patient's stomach pain and vomiting, you can report a procedure code and the E/M service.

How? Make sure you provide solid documentation on both procedures and link the appropriate diagnosis codes to each service the gastroenterologist provides.

On your claim, you should:
 

  •  report 43202 (Esophagoscopy, rigid or flexible; with biopsy, single or multiple) for the esophagoscopy.
     
  •  attach ICD-9 code 530.10 (Esophagitis, unspecified) to 43202 to represent the patient's esophagitis.
     
  •  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.
     
  •  attach 536.8 (Dyspepsia and other specified disorders of function of stomach) to 99212 to represent the patient's stomach pain.
     
  •  attach 787.03 (Vomiting alone) to 99212 to represent the patient's vomiting.
     
  •  attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99212 to identify the service as separate from the esophagoscopy.

    In this instance, you are allowed to report both codes because the E/M service was a significant, separate service from the esophagoscopy. However, if the gastroenterologist performed the esophagoscopy and then provided E/M service for stomach pain and vomiting related to the procedure, the E/M would be bundled into 43202.

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