ASGE members may submit coding inquiries electronically to codingquestions@asge.org. Each month ASGE gets dozens of questions from members. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Full patient and practice information is a violation of HIPAA privacy rules and questions will be sent back without an answer. Below are two questions on the new Evaluation and Management guidelines.
Question #1
Does ordering a colonoscopy or EGD constitute a minor surgery? I'm trying to figure out if this meets moderate risk and if an endoscopy is considered "minor surgery".
Answer #1
Yes, per the new guidelines for CPT 99202-99215, this is considered minor surgery and would support level 3 based upon risk. The diagnosis managed would be considered moderate since this is a new problem with uncertain prognosis. It will all come down to the data section of Medical Decision Making (MDM) as to whether or not this is overall low or moderate decision making.
Question #2
I need clarification on prescription drug management. If a patient is seen for GERD and was prescribed Omeprazole 20mg by their PCP, and we state that they are doing well on that medication and recommend continuing the medication, do we not get credit for prescription drug management since we did not write the script?
Answer #2
Yes, that is correct since your provider didn't write the script.
Question #3
I understand we can report the total time of the patient encounter for office visits starting January 1, 2021. Can you give some examples of activities we can include in the total time?
Answer #4
Here are some activities that can be included in your time spent:
- Previous chart review and/or outside record review
- Time spent examining the patient
- Time spent speaking with other providers regarding the patient's care
- Ordering medication, tests, or other procedures
- Time spent documenting the patient's encounter
Note: Time spent in these activities must be performed on the date of the encounter. Time spent by clinical staff does not count, this is only provider time.