Gastroenterology Coding Alert

When your gastroenterologist sees a Medicare inpatient and would have used an inpatient consultation code, this year you should report an initial hospital care code 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...). If the E/M service and documentation do not meet the requirements of an initial inpatient hospital care code, however, your coding will now depend on your Medicare Administrative Contractor's (MAC) or carrier's policy.

Problem: The lowest initial hospital care code (99221) requires a detailed history and detailed exam. When your gastroenterologist's documentation does not reach this level, there is a question as to what CPT codes you should use.

At the beginning of the year some MACs/carriers stated that you should use the subsequent hospital care codes (99231-99233). "Our MAC (Highmark) has actually stated to not use 99499 (Unlisted evaluation and management service) for consultations and to use subsequent care codes," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., and senior coder and auditor for The Coding Network.

Mixed advice: Other MACs, however, had instructed practices to use the Not Otherwise Classified (NOC) code 99499, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/ GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. On March 3, however, CMS advised all carriers to revise policies to accept 99231-99233 in place of 99499 when documentation requirements don't support 99221-99223.

Important: Because five levels of inpatient consults are now billed using only three levels of inpatient E/M visits, some practices are seeking crosswalks that refer them from consult codes to E/M codes. But you should not rely on any such guides as the final word. Instead, when the practitioner performs an E/M service, report the code "that most appropriately describes the level of services provided," notes MLN Matters article MM6740.

Answer 2: Stick With Two Letters for the Admitting Physician

Admitting physicians now have a new modifier for their initial inpatient service. As of Jan. 1, if you're coding for the admitting physician you must append modifier AI (Principal physician of record) to the initial visit code.

This will denote the admitting physician who is overseeing the patient's care "as distinct from other physicians who may be furnishing specialty care," according to CMS Transmittal 1875 (www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf).

Example: A trauma surgeon admits from the emergency room a patient who was involved in a motor vehicle accident and calls in the gastroenterologist to perform a consult for colon perforation. The trauma surgeon would report 99221-99223 with modifier AI appended. The gastroenterologist then bills 99221-99223 with no modifier for his initial examination of the patient whether the visit represents a consultation or a new visit.

Remember: The new modifier is made up of two letters. "Some people are interpreting the new modifier as a one," Cobuzzi says. "But it's two letters, A and I," she reminds coders. Think: A-eye.

Answer 3: Skip 99241-99255 for Medicare, Even as Secondary

Don't even think about billing a consult to Medicare -- even if the claim is headed to a Medicare secondary payer (MSP).

The challenge: Medicare may have scratched consultation codes off its list of payable services, but many other insurers did not follow suit. This dual system leaves you in a quandary when your physician performs a consultation and the primary non-Medicare insurer pays for the consultative service, but the secondary payer is Medicare. The MSP "will not pay for consults," says Samantha Daily, medical biller for Urologic Consultants PC in Portland, Ore.

Official word: MLN Matters article MM6740 indicates the following: "In MSP cases, physicians and others must bill an appropriate E/M code for the services previously paid using the consultation codes [99241-99255, Office or other outpatient consultation ...]. If the primary payer for the service continues to recognize consultation codes" you should bill for secondary payment from Medicare in one of the following two ways:

1. Bill the primary payer using an E/M code (not a consultation code), and then report the amount paid by the primary payer, along with the same E/M code, to the MSP for determination of whether additional payment is due; or

2. Bill the primary payer using a consult code, and then report the amount paid by the primary payer, along with an acceptable E/M code (that is equal to the consultation code/service paid), to the MSP for determination of whether you are owed additional payment.

Potential snag: In some cases the gastroenterologist may not know whether a hospitalized patient is on Medicare or other insurance when he documents his consultation and determines code assignment. You will need to be able to glean an appropriate E/M code from your gastroenterologist's consult documentation if the patient ends up also having Medicare as secondary insurance.