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 …).

@ Gastroenterology Coding Alert

Be a hero. Join the coding community at the Supercoder Fan Page.

Get the scoop on the value of customer service and how it leads to patient retention in the Power of Customer Service for Physicians and Staff audio conference.

Related articles:

1. E/M Challenge: Can I Report 99214 and +99354?Counseling representing more than 50 percent of E/M visit? Choose...
2. E/M Coding: Don’t Sell Yourself Short on Problem Sports ExamsTip: Time-based E/M might be in line when managing diabetes,...
3. How Do I Code Genetic Counseling By A PhysicianLimit 96040 to Trained Counselor Question: May we report 96040...

5 tips help you recover deserved pay.

Collecting money from patients, especially during a recession, can be challenging. If your front desk is responsible for collecting copays and sometimes old balances, its success or failure has a dramatic impact on the practice’s bottom line.

Check out five ways you can improve your front desk collection efforts:

1. When calling to remind patients about their visit date, also remind them of their co-pay amount and any old balances so they come prepared to pay at the visit.

2. When a patient complains about paying a bill, send her to a manager so the bill can be reviewed and explained.

3. Most practice management software will allow front desk staff to view outstanding balances. Your front desk staff can politely remind the patient that there is a balance and say something like, “How would you like to pay your bill today?” Assume that the patient is planning to pay.

4. If the patient has a problem paying their balance or paying for the visit that day, do not discuss this at the front desk. Respect his privacy. Staff may wish to take him to a manager’s office where a payment plan or other arrangement can be established.

5. Ask your manager about offering discounts to patients with no insurance if they pay for the visit at checkout instead of sending them a bill.

And one extra tip: Involve Your Supervisor. Pearl Stafford, front office manager for an internist and gastroenterologist in Naples, FL, who also once worked for a psychiatrist where she assumed the role of the receptionist from time to time, acknowledges that old or really old AR can be difficult to collect. “A lot hinges on the physician,”says Stafford. “In this particular office, my physician provided incentive. Since the AR was so old in many cases, he offered me 25 percent of anything I collected. Most collection agencies charge 50 percent, so this was beneficial to the practice and also worked as an incentive for me.” If something is really old, it’s better to collect some money as opposed to nothing and wipe it off the books.

Carol Gibbons, CEO of CJ Consulting, helps management to set up collection targets for the front desk and then rewards staff when they reach that goal. “In one practice with seven physicians, the front desk as collecting $500 per day at the front desk. After doing training with the front desk staff, we started pushing up their collection goal and then bought lunch each time they reached a new goal. Today, at the front desk, that office collects $2,500 to $3,500 per day in co-payments, co-insurance, and old balances. The manager still buys pizza when they reach a new high in daily collections or rewards individual employees with gift cards.”

Again, your specific role in collections will vary, but these are some ideas that you may wish to present to your manager or physician if they are not yet implemented in your office.

© Supercoder. Sign up for your free, 30-day trial here.

Coming soon to audio. Save hundreds with these A/R best practices.

Related articles:

1. Medical Billers: Test Your Collections Know-How Here This nifty tool tells you if collections cluelessness is...
2. Time Your Surgical Collections Right by Referencing Payer Contracts Find out if you’re legal in collecting patient portion...
3. Overcome ‘Forgot the Checkbook’ Excuses With This Checklist   When you get the old “I forgot my...

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.

@ Gastroenterology Coding Alert

Become a gastroenterology coding hero by attending Jill Young’s Things You Shouldn’t Have to Swallow in Gastroenterology Billing audio conference. Reserve your spot today!

Related articles:

1. Gastroenterology Coding Education: Bravo Cap Placements Question: A new patient reports to the gastroenterologist with complaints...
2. How Should I Code a Fibrinolytic Agent Instillation Via Chest Tube?Different calendar dates matter, but multiple instillations the same day...
3. Winter Laceration Repair: How Do I Code For Dermabond?Warning: Your coding will vary depending on who’s getting the...

Question: A local family physician refers a patient to our gastroenterologist for a diagnostic colonoscopy. The patient reports to the practice and meets the gastroenterologist for the first time. After answering some patient questions during a brief introduction, the gastroenterologist performs a diagnostic colonoscopy with brushing. The patient had never met the gastroenterologist before. Is the time he spent with the patient pre-screening a separate E/M?

Related articles:

1. Are These Colonoscopy Codes Bundled?Challenge: Can you report codes 45380 and 44388 together? Answer:...
2. Don’t Wait for CPT: Maximize Virtual Colonoscopy Payment Now Learn whether to file an ABN with 0066T, 0067T....
3. Gastroenterology Coding Education: Bravo Cap Placements Question: A new patient reports to the gastroenterologist with complaints...

Coding Hint: Watch for ‘add-ons’ during Remicade sessions

Related articles:

1. Oncology Coding Challenge: When Infusion Runs Long Question: The oncologist ordered a 90-minute chemotherapy infusion service,...
2. CODING CHALLENGE: Is V58.11 Right for Patient Not on Chemo? Question: When you use a chemo admin code for...
3. Gastroenterology Coding Education: Bravo Cap Placements Question: A new patient reports to the gastroenterologist with complaints...