Coding Strategy

Choose the service level using the documented history, exam, and MDM.

Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicate that she spent 21 minutes advising the patient on proper diet and medication management. Is this an instance where I can code based on total encounter time?

New Jersey Subscriber

Answer: Maybe. Go back and double-check both the total encounter time and the amount of time the spent on counseling by either the physician or any NPP.

If the provider spends at least half (16 min) of the total session time counseling the patient, then report …… 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity … Physicians typically spend 30 minutes face-to-face with the patient and/or family) for the encounter, based on the total time the provider spent face-to-face with the patient, with 531.7 (Gastric ulcer; chronic without mention of hemorrhage or perforation) appended to represent the patient’s condition.

Don’t stop there: Whenever you invoke the counseling exception for E/Ms, be sure the patient’s medical record has good documentation of the session. For instance, a good note for your scenario might read: “Spent total of 34 minutes with patient. Talked about medication options and possible side effects for 15 minutes, and about diet and ulcer management for 6 minutes.”

Remember: If you cannot enact the counseling exception for this encounter and code based on time, you must code based on the key elements. Choose the service level using the documented level of history, examination, and medical decision making the physician provides. In your case, the visit’s key components would qualify as 99202 (… an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making …).

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Reading 44373’s code descriptor is key to getting your G Tube claim right.

Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the tube. I cannot find a code for repositioning a G tube; how should I code this scenario?

Answer: Judging by your encounter description, the patient’s percutaneous jejunostomy tube (J tube) slipped and became a percutaneous gastrostomy tube (G tube). On the claim, report the following:

• 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneousgastrostomy tube to a percutaneous jejunostomy tube) for the EGD;
• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …) for the E/M;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99231 to show that the E/M and tube fix were separate services; and
• 536.42 (Disorders of function of stomach; gastrostomy complications; mechanical complication of gastrostomy) appended to 44373 and 99231 to represent the patient’s condition.

Explanation: The descriptor for 44373 might be a bit misleading, but it mentions only “tube conversion.” The tube does not necessarily have to be new.

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Counseling representing more than 50 percent of E/M visit? Choose level based on time.

Question: I have a family physician who documented 60 minutes on an established patient’s office visit. The FP diagnosed the patient with morbid obesity (278.01). Since the patient was newly diagnosed and had some difficulty understanding the doctor’s orders, the FP spent more than half the office visit time on counseling on therapeutic lifestyle changes and the treatment regimen. Should I code this as 99214 for the first 25 minutes and +99354 for the remaining time?

Answer: No, since counseling and/or coordination of care takes up the majority of this office visit’s time (counseling represents more than 50 percent of the total time with the patient), choose the level of E/M service based on time. You can assign prolonged services for any remaining established patient office visit time only when assigning 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity … Physicians typically spend 40 minutes face-toface with the patient and/or family). “In those evaluation and management services in which the code level is selected based on time, prolonged services may only be reported with the highest code level in that family of codes as the companion code,” according to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.15.1, “Prolonged Services with Direct Face-to-Face Patient Contact Service.”

You can capture only the 40 minutes of your encounter. CPT associates 40 minutes as 99215’s typical/average time.

Therefore, use the highest level office visit code: 99215. You lose the additional 20 minutes. Since the FP in this encounter spends only an additional 20 minutes on this encounter beyond 99215’s typical time, the encounter does not meet prolonged service code +99354’s “threshold” time of thirty minutes. You don’t need to report a prolonged service code in this situation.

CMS does not allow you to game the system by adding prolonged services onto a lower level office visit code for more relative value units (RVUs). Since in your scenario, the E/M service code level will be based on time, selecting the following codes will not be appropriate:

• 99214 — Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family)

• +99354 — Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient evaluation and management service).

Refer to the Medicare Claims Process Manual’s Chapter 12 here.

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