Gastroenterology Coding – Some Tips


Consultation codes are not used for Medicare patients now. Therefore a patient coming to your office for the first time has to be billed using a New Patient Visit code from the range 99201-99205, provided no one else in your office in the same specialty has given face-to-face service to the patient in the past three years. In case the patient has been provided service within the last three years, the codes should be from the Established Patient Visit in the range 99211-99215. Even if the Medicare patient is admitted for some other problem, you can only bill using the Established Patient Visit code, if the patient has already been seen within the last three years.

Consultation codes can be used for private insurance companies.

Documentation for a Medicare patient seen in the hospital should be with the Initial Hospital Visit codes. The Modifier AI has to be added in case you are the admitting physician. A patient seen in the Emergency room has to be billed using codes from the range.

Medicare demands a clearly documented History and Physical Exam or H&P before any procedure carried out at an Ambulatory Surgery Center (ASC). This H&P procedure is treated as part of the procedure provided and cannot be billed separately.

A gastroenterologist carrying out H&P for a patient presenting with symptoms at his office, and then deciding that an immediate procedure is required can bill for both the procedure and visit on the same day. However, the E/M service during which the physician made the decision to perform the procedure should be documented. The 25 modifier has to be added along with the visit code.

A reduced service is signified by the modifier 52. An instance is when the physician plans to do an EGD, but fails to advance the scope to the duodenum probably due to an obstruction. Here he cannot bill for an esophagoscopy, but can report an EGD with the 52 modifier.

Medicare distinguishes between average risk patients and high risk patients when it comes to screening colonoscopy. The time restrictions differ in both cases, with it limited to once in every 10 years for average risk patients and once every 24 months for high risk patients.

If a new patient is seen by a physician assistant or nurse practitioner at the office, and they discuss the patient with the physician later on, the visit can be billed only under the physician assistant’s or nurse practitioner’s NPI/provider number, unless otherwise instructed by the payer in writing.

A diagnostic endoscopy (43200) is always included in a surgical endoscopy. A diagnostic endoscopy carried out along with a surgical endoscopy in the same session cannot be separately reported.

Coding for Vitamin B12, iron and interferon injections has to be done with discretion. Two therapeutic codes 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) or 99211 (established patient office or other outpatient visit), can be used to report this procedure. These are also called non-physicians’ codes because they do not demand a gastroenterologist to be present in the room. 99211 is the higher valued code and CPT and Medicare differ regarding its use. According to CPT, this code can be used to report an injection given, even that given on a weekly basis. For Medicare reimbursement:

• Medical necessity has to be shown when reporting this code.
• For a 99211 visit, the gastroenterologist need not see the patient. But the documentation must show that he/she gave some direction for this service.
• The nurse has to document the office visit in detail and get the gastroenterologists’ signature on it.


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