Primary Care Coding Alert

Question: An established patient with a plan of care in place for her gastroesophageal reflux disease (GERD) reports to the FP. Two weeks ago, the FP started her on Nexium (esomeprazole). One of the practice's nonphysician practitioners (NPPs) evaluates the patient, taking blood pressure and other vitals. She also asks the patient if she has experienced any nausea, diarrhea, vomiting, or any other side effects since she started Nexium. The patient reports that she's "thrown up three or four times" since starting the medication, but reports no other side effects. The patient's record indicates that the FP scheduled this visit specifically to check how the patient's adjustment was going. What can I report for this encounter?

Montana Subscriber

Answer: Coding will depend on the encounter specifics, but this sounds like a 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services.) service.

No matter what E/M code you choose, be sure to include 530.81 (Other specified disorders of esophagus; esophageal reflux) to represent the patient's GERD and 787.03 (Vomiting alone) to represent the patient's persistent vomiting.

Explanation: The FP will often order a patient to report soon after starting a new medication regimen; these scheduled visits are typically 99211 encounters, though they can theoretically be higher-level if some complications arise.

For medication checkup encounters, insurers might want to see a clear explanation as to why the E/M was necessary. Cut off any payer queries by including the following 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 FP evaluated the clinical information the NPP obtained and made a management recommendation for the patient.

If the NPP is a nurse practitioner or PA whose license allows her to provide services at a level above 99211, such documentation may support a higher level of service (e.g., 99212), especially if the NP or PA evaluates the clinical information and makes a management recommendation for the patient.