Coding Strategy

This modifier is key to E&M and counseling codes cohabiting on your claim.

Question: Can I report alcohol cessation counseling codes along with E/M codes, or do I have to choose one or the other?

Idaho Subscriber

Answer: You can, and in most cases will, report counseling codes along with E/M services. The behavior change intervention codes are intended to be reported in addition to an E/M service when the provider furnishes them. Most counseling sessions occur after the provider performs some sort of E/M. Consider this case study:

A new patient presents to the gastroenterologist reporting intense heartburn and “vomiting bile” for about a week. The patient’s skin is a splotchy yellow, and he reports experiencing generalized fatigue “for as long as I can remember.” Due to the smell of alcohol and the patient’s symptoms, the physician asks the patient if he has been drinking. The patient says “Yes,” so the physician decides to conduct the CAGE test to gauge alcohol abuse

Based on the test results, the physician determines that the patient is at least moderately dependent on alcohol; she performs extensive counseling and recommends the patient start attending Alcoholics Anonymous or some other community support group for alcohol-addicted individuals.The physician then finishes her patient exam.

She also recommends that the patient schedule a follow-up visit for a cirrhosis screening. The alcohol counseling lasted 18 minutes, and notes indicate the physician also performed a level-two E/M.

In this instance, the gastroenterologist performs both an E/M service and alcohol counseling. On the claim, you would report the following:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decisionmaking…) 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 99202 to show that the E/M was a separate service from the counseling;
• 787.04 (Bilious emesis) appended to 99202 to represent the vomiting;
• 787.1 (Heartburn) appended to 99202 to represent the heartburn;
• 782.4 (Jaundice, unspecified, not of newborn) appended to 99202 to represent the skin condition;
• 780.79 (Other malaise and fatigue) appended to 99202 to represent the patient’s fatigue;
• 99408 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT, DAST], and brief intervention [SBI] services; 15 to 30 minutes) for the counseling service; and
• 305.00 (Alcohol abuse; unspecified) appended to 99408 to represent the patient’s alcohol dependence.

@ Gastroenterology Coding Alert. Editor: Chris Boucher, CPC

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Don’t be caught asleep: Patient history is one element of proper Dx coding.

Many coders hesitate to report V codes, or simply use them incorrectly, but sometimes this section of ICD-9 most accurately describes the reason for the patient’s condition. In fact, V codes are often essential to reporting an anesthesia patient’s medical history.

If you’re not clear on the importance of V codes, check out these expert-approved answers to some often-asked questions:

Why Should I Use V Codes?

To determine if you should use a V code, look for documentation in your anesthesiologist’s report that will support physical status modifiers or use of Monitored Anesthesia Care (MAC), says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Knowing that a patient has a history of certain problems (such as a history of sudden cardiac arrest) could affect how your provider delivers anesthesia or monitors the patient. The personal history might also help justify having anesthesia services available (either already providing service or with the anesthesiologist on stand-by) for procedures that might not normally need anesthesia.

Important: V codes are not only appropriate as secondary codes. You may occasionally encounter a situation where a V code is necessary as the primary diagnosis. In some cases, reporting a V code might be the only way you’ll be paid for a service.

“If there are chronic conditions that affect the physical status, such as diabetes, lung disease, or cardiovascular disease, then these should be coded in addition” to the current diagnosis codes, says Julee Shiley, CPC, CCS-P, ACS-AN, a coding professional in North Carolina.

Example: A gastroenterologist requests your anesthesiologist at a colonoscopy because the patient has been resistant to moderate sedation in the past. Using V15.80 (History of failed moderate sedation) could justify why the anesthesiologist was at the colonoscopy.

Look for Symbols Indicating V Code Use

“Coders that are not aware of the ICD-9 history codes often err and report the ICD-9 code(s) indicating that the patient has the active or ongoing condition, rather than reporting the compliant and associated patient history code,” Dennis says.

If you find it tricky to distinguish primary from secondary V codes, ICD-9 gives you some helpful hints. Many versions of the ICD-9 manual use a symbol, such as a “1” or a “2” inside a circle, to indicate in what order you should report the code (such as “first listed or primary Dx,” “first listed or additional,” or “additional or secondary Dx only”). You’ll find these indicators next to the code descriptor.

Example: An anesthesiologist provides MAC to a patient with a history of transient ischemic attack (TIA), an episode in which a person has stroke-like symptoms for less than 24 hours. According to ICD-9, you may report V12.54 (Stroke [cerebrovascular]) as the primary diagnosis and the reason for the surgery as the secondary diagnosis.

How Do I Use V Codes For Anesthesia?

Use of V codes for anesthesia can be very different from other specialties’ use of the codes. Find out how by subscribing to the Anesthesia & Pain Management Coding Alert.

Editor: Joshua Thines

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Following 10-year-rule eliminates G0121 rejection.

If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch.

Use this guidance to capture every screening dollar your gastroenterologist deserves.

Home in on Eligibility Requirements for Average-Risk Test

Any Medicare patient 50 years or older is eligible for a covered Medicare screening, explains Dena Rumisek, CPC, biller at Grand River Gastroenterology PC in Michigan. These patients can have a colorectal cancer screening only once every 10 years. You’d be wise to pay attention to the frequency guidelines, as “Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days” between covered screening colonoscopies, Remise warns.

Example: A 73-year-old established Medicare patient with average risk for colorectal cancer reports for a screening colonoscopy on Feb. 11, 2009. The patient’s records indicate that he last had a covered screening on Jan. 31, 1999. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

One bit of simplicity: Report G0121 if there is no need for any therapeutic intervention during the colonoscopy. All G0121 claims require only one diagnosis code: V76.51 (Special screening for malignant neoplasms; colon). “If the chart shows a diagnosis such as colitis, you shouldn’t be reporting a screening,” says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA’s CPT Advisory Panel.

Error averted: The chart notes and the procedure diagnosis should be consistent. “This is something the OIG and RAC auditors are scrutinizing,” Weinstein says.

Change Your Coding for Recent Sigmoidoscopy

The frequency rules differ depending on whether other related colorectal cancer tests were performed previously. If a patient has had a routine flexible sigmoidoscopy screening (G0104, Colorectal cancer screening; flexible sigmoidoscopy), he is not entitled to a screening colonoscopy for at least 48 months.

Example: An average-risk established Medicare patient reports to the gastroenterologist for a screening colonoscopy on March 18, 2010. The patient’s medical record indicates that he had a flexible sigmoidoscopy screening on April 7, 2007.

This patient is not now eligible under Medicare guidelines for a screening colonoscopy because it has been only three years since his sigmoidoscopy. Therefore, you cannot report G0121 for the March 2010 procedure and expect payment from Medicare.

Alter the Rules for High-Risk Patients

A patient who is considered at high risk for colorectal cancer might be entitled to a screening colonoscopy as frequently as once every 24 months. You’ll list a V code (such as V10.05, Personal history of malignant neoplasm; large intestine, or V12.72, Personal history of certain other diseases; diseases of digestive system; colonic polyps) as the primary diagnosis for these tests — most of the time.

Exception: If a patient has a condition that automatically puts him at high risk for colorectal cancer, then you would list that condition as the primary diagnosis (for instance, Crohn’s disease or ulcerative colitis; check your local coverage determination [LCD] for your payer’s specific list).

Example: A 69-year-old established Medicare patient with a personal history of colonic polyps reports to the gastroenterologist for a colonoscopy screening on March 1, 2010. The patient record indicates that the patient’s last colonoscopy screening was Feb. 4, 2008. On the claim, report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) with V12.72 appended.

Beware Private Payer Screening Differences

Some private payers will reimburse for colonoscopy screenings — their coding practices for these services, however, can differ from Medicare. Many U.S. states have passed legislation similar to the Medicare regulations requiring all health insurance companies to cover routine colorectal cancer screening starting at age 50. Most non-Medicare payers accept 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing; with or without colon decompression [separate procedure]) for a screening colonoscopy. Before coding these services, check the payer’s frequency and diagnosis guidelines. Each payer reimburses for screenings according to the patient’s policy.

G codes possible: Other private payers might want you to code the same way as Medicare. For instance, Blue Cross Blue Shield of Michigan accepts the G codes nd follows most of the same diagnosis guidelines as Medicare, says Rumisek.

Best bet: Check with your private payers before coding any screening colonoscopy services.

@ Gastroenterology Coding Alert, Editor: Caroline Harris

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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

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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.

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