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Gastroenterology Coding Alert

10 Tips to Differentiate Consultations and Referrals

Published on Sun Sep 01, 2002

Because consultations reimburse more than referrals, they're a tempting coding option to gastroenterologists, but remember to follow 10 guidelines to avoid raising a red flag.

Assess Whether Care Was Transferred

"A consult is a service rendered to give an opinion to a requesting physician about a patient's condition," says Kristine D. Eckis, CMM, CPC, president of The Bottom Line Medical Administrative Consultants Inc. in Lake Wales, Fla. "A referral is the transfer of responsibility for a patient's care from one physician to another.

"The gastroenterologist can initiate treatment during a consultation," she says. "For example, the patient may need medication, and the gastroenterologist writes a prescription. But the patient eventually returns to the physician who initially requested the consult. The gastroenterologist does not assume care."

Determine Intent for Visit

Consultations are distinguished by the intent of the visit, adds Jennifer Swindle, RHIT, CCS-P, CPC, coding reimbursement services supervisor for a multi-specialty, 150-physician clinic in Lafayette, Ind. "Typically the physician who requests the consult knows the patient has a problem outside of his or her areas of expertise," she says. "The physician knows that specialized care is needed and sends the patient to be evaluated for treatment."

Look for Circle of Care

Swindle finds it helpful to think of consults as a "circle" of care. The requesting physician sends the patient to the specialist, the specialist provides treatment and, at the conclusion of the consultation, sends the patient back to the requesting physician. The specialist also sends to the requesting physician a written report of his or her findings and the treatment rendered. If the gastroen-terologist is taking over the patient's care, however, the circle is broken.

Know the Consultation and Referral Codes

For consultations in the office or other outpatient setting, use 99241-99245 (Office consultation for a new or established patient). Report inpatient consultations 99251-99255 (Initial inpatient consultation for a new or established patient).

For referrals, use a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient,), Eckis says. The gastroenterologist assumes care for the patient's problem, which often involves subsequent visits, surgical procedures, ongoing treatment or follow-up care.

Consider the Gastroenterologist's Role

It is rare for her physicians to be asked to take over complete care of a patient, says Lois Curtis, billing manager for a seven-physician gastroenterologist practice in Indiana. Thus referrals are uncommon in her experience. On the other hand, consults are common.

"Frequently a primary-care physician suspects a problem, such as colitis, and sends the patient to us to diagnose and treat that specific problem," Curtis says. "That physician expects, and we provide, a complete report of our findings and treatment."

Curtis explains that primary-care physicians sometimes send patients with a review of symptoms, or include additional useful information for the gastroenterologist.

"We may get a letter requesting a consult for a patient who is experiencing diarrhea and blood in the stool," she says. "Or the physician may tell us the patient has intense heartburn and abdominal pain or even chest pain, which could indicate reflux disease. They also may advise us that they've run the gamut of cardiac tests to rule out heart problems. Sometimes they also give the go-ahead for a diagnostic endoscopy if necessary."

Initial Contact May Constitute Consultation

Even when the consulting gastroenterologist ultimately takes over care of the patient because of the eventual diagnosis, such as Crohn's disease, the initial contact with the patient is still considered a consultation for coding purposes, says Michael L. Weinstein, MD, Metropolitan Gastroenterology Group PC, Washington, D.C., and prior American Society for Gastrointestinal Endoscopy (ASGE) representative to the CPT advisory board. "At the time of the first visit, it was not known that the consulting gastroenterologist would take over care," he says.

Look for Three R's in a Consult

Three elements of care characterize a consult, Eckis explains. If these three are present, the visit qualifies as a consult:

  • Request. One physician requests the opinion of another. Note: Although the request often originates from a physician, any healthcare provider can initiate a consult. The request does not need to be in writing. A written request in the patient's chart is ideal documentation, but it is also adequate for the gastroenterologist to mention the request in the office notes.
  • Review. The gastroenterologist reviews the patient's condition in person, and the patient is present for this review.
  • Report. The gastroenterologist sends a written report back to the requesting physician.

    Document each element in the patient's chart, Eckis says. "The Office of Inspector General and your state's attorney general would consider billing for a consul-tatation fraudulent if the request, review and report are not documented."

    Rethink the Word 'Refer'

    Eckis advises using the term "consult" in the report, a tactic that makes the nature of the visit very clear should there ever be an audit of the information.

    Swindle agrees. "Many physicians in our large clinic 'refer' patients to other physicians in the clinic," she says. Physicians should refrain from using the word "referral" in their correspondence to other doctors, because the colloquial expression has different implications from the coding term.

    To rectify the situation, the gastroenterologist might write in the report back to a requesting physician, "Thank you for asking me to see this patient," she suggests.

    "So many times, the physician will write 'Thank you for the referral' to a professional colleague," Eckis says. "I suggest something such as 'Thank you for your request to render a consult.' "

    Take Advantage of Confirmatory Consult Codes

    When a gastroenterologist is asked to provide a second or third opinion about the medical necessity or appropriateness of a procedure, assign confirmatory consultation codes 99271-99275 (Confirmatory consultation for a new or established patient).

    "These codes can be used with new or established patients, when the patient wants a second opinion, or if an insurer requests the gastroenterologist's opinion," Eckis says. "When a third-party payer requires the consult, report the service with modifier -32 to indicate a mandated service."

    Confirmatory consult codes don't reimburse as much as the regular consult codes, Eckis says, but they offer five additional codes to report appropriate services. Most insurance carriers, including Medicare, do not cover confirmatory consults requested by a patient or family member, so you should secure a signed waiver from the patient acknowledging his or her responsibility to pay for the service.

    Understand New Business Versus Multiple Visits

    Referrals are coded like new patient visits, Eckis notes, and should be viewed as "new business." Physicians want to use the consult codes, she adds, because they know that consults pay more than new patient visits. Reimbursement aside, if consult codes do not accurately describe the service provided, they can't be used.

    "Many times consults are a one-time service," Eckis says. "On the other hand, referrals often involve surgery or specialized procedures as part of the treatment. And that all adds to the reimbursement."

    Consults often involve two to four visits to complete evaluation and testing, and conclude with a diagnosis and treatment plan, Weinstein says. "The follow-up visits to complete the evaluation can be billed with the established patient codes (99211-99215) or, if appropriate, a procedure code," he explains.

    If a patient returns to the gastroenterologist at the request of his or her physician or provider even within three years, the visit can be billed again as a consult. "This assumes the patient's condition has changed and a specialist opinion is needed to redirect management," Weinstein says. "And again the three-R's criteria must be met. A specific minimal interval between consultation visits has not been established, but six months is probably reasonable."

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