We are a large colon and rectal practice. One of our most challenging jobs is correctly coding the E&M visits. We code from the ambiguous 1995 guidelines. The trouble is in determining what constitutes the different levels of an exam for our specialty. Does anyone have a recommendation for each exam level; specifically a detailed vs. comprehensive? Recently, an AAPC conference leader suggested an 8 system exam as a comprehensive. However, our surgeons are concerned that performing an 8 system exam, on even the more serious patient, would lead to questions of medical necessity. There is a grey area between performing an exam for E&M purpose versus a pre-operative work-up.

Secondly, there is an issue of billing an anoscopy or rigid proctosigmoidoscopy with 99201-99205 and 99241-99245. The correct coding initiative allows them to be billed on the same day as an E&M code; however, most carriers deny the E&M stating it is part of the procedure. Our appeals are denied as “incident to.” The physicians are performing the anoscopy/ rigid sigmoidocopy as diagnostic in order to formulate an assessment and plan. For example, it a patient comes in with complaints of anorectal pain and bleeding our physicians may perform an anoscopy to evaluate the sources of the symptoms before making an assessment and plan. In theory, the physician is halting the E&M process after the system exam to perform the procedure. They then resume the E&M process with the assessment and plan. What is the stance for the correct coding of an E&M with these procedures?

Anna Barnes, CPC, CGSCS