Gastroenterology Coding Alert

For referrals in the office setting, you use a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient), says Kristine D. Eckis, CMM, CPC, president of The Bottom Line Medical Administrative Consultants Inc. in Lake Wales, Fla. In such a case, the specialist assumes care for the patient's problem, which often involves subsequent visits, surgical procedures, ongoing treatment, or follow-up care.

What's in a Name: Defining Consults and Referrals

"A consult is a service rendered to give an opinion to a requesting physician about a patient's condition," Eckis says.
 
For example, a patient presents to his primary-care physician (PCP) complaining of bloody diarrhea and severe stomach cramping. Suspecting ulcerative colitis, the PCP contacts a gastroenterologist and sends the patient to the specialist for an evaluation to diagnose the symptoms. The PCP also sent the gastroenterologist a request for the consultation and the patient's review of symptoms. The gastroenterologist examines and diagnoses the patient then prepares a complete report of his findings and a proposal for treatment, which he sends back to the PCP.
 
The gastroenterologist's service is considered an office consultation and would be coded using the appropriate code from the 99241-99245 range.
 
"A referral, on the other hand, is the transfer of responsibility for a patient's care from one physician to another," Eckis says. And while many referrals take the shape of office visits that you should bill using the new and established patient office visit codes, they won't always be E/M services.
 
For example, a patient presents to his family doctor for his annual exam. The physician recommends that the patient have a screening colonoscopy and refers the patient to your gastroenterologist. The physician performs a complete evaluation of the patient and gives clearance for the gastroenterologist to perform the screening procedure that day. 
 
In this case, you would report just the code for the screening colonoscopy because the physician did not request the gastroenterologist's opinion, nor was it necessary for the specialist to evaluate the patient prior to the procedure.
 
The intent of the visit is key for defining consultations, says Jennifer Swindle, RHIT, CCS-P, CPC, CCP, coding reimbursement services supervisor for a multispecialty 150-physician clinic in Lafayette, Ind. "The physician who requests the consult is seeking the evaluation and opinion of another," she says. "The consultant may or may not provide treatment at this visit, but the intent of the visit was for his or her opinion."
 
Swindle finds it helpful to think of consults as a "circle" of care. The requesting physician sends the patient to the specialist, and the specialist provides evaluation and opinion and, at the end of the consultation, sends the patient back to the requesting physician. The specialist also sends to the requesting physician a written report of his findings and any treatment that may have been rendered. If the specialist takes over the patient's care, however, the circle is broken.
 
When a primary-care physician sends the patient to a gastroenterologist with the intention that the specialist will assume treatment for the patient, this service is a referral or a transfer of care. In such a case, the specialist treats the patient and then follows up with the patient for the care of his condition.
 
Billing for a consultation when the service provided doesn't meet the definition of a consult can land a practice in hot water with the OIG and with the state attorney general - not to mention invite an audit.

Documentation Is Vital ... Be Careful Using 'Refer'

Gastroenterologists must pay particular attention to their documentation - whether they are requesting or delivering a consultation - to provide an accurate record of the patient's treatment.
 
Always make sure the physician documented the request for a consultation in the patient's record, whether the initial request was verbal or written. Carriers require this documentation to consider the consult code valid. Under the best circumstances, you should keep documentation of this request in the patient's charts - both at the primary-care physician's office and the specialist's office.
 
The wording of the request is important. Physicians should avoid using the word "referral" when they are actually requesting a consultation. Use of this word can imply a transfer of care and can be a red flag to auditors. Eckis advises using the term "consult" in the request, a tactic that makes the nature of the visit very clear should there ever be an audit of the information.

Physicians reporting back to the requesting physician following a consultation should be equally careful with "refer," she adds. "In many cases, physicians will write a note stating, 'Thank you for referring Anne Smith to me ...' This is fine for referrals. However, for consults, more appropriate wording would be, 'Thank you for your request to render a consultation ...' "
 
This can also mean trouble for the specialist in the event of a postpayment audit. In the above example, a primary-care physician asked a specialist for a consult. The specialist completed the consult, fulfilling the requirements of the service, including sending the report to the requesting physician.
 
In the course of evaluating the patient, the specialist decided that he should follow the patient's care for the particular problem. However, in his note to the original physician, he thanks the pediatrician for referring the patient to him, when he had, in fact, delivered a consult.
 
In an audit, a carrier might consider the initial code for a consultation inaccurate, due to the slip in semantics. "It sounds as though the requesting physician sent the patient over to the specialist, expecting the specialist to assume care," she says. If that were the case, a consult code would not be valid.
 
While the documentation for consultation services should try to avoid the terms "refer" or "referral, it is not wrong and does not mean that a consultation service was not delivered, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C. Specialists frequently see patients for a particular problem at the suggestions of their PCP. The specialist can evaluate the patient, perform tests and procedures as needed, and treat the condition. The summary of the care should be related back to the PCP. Even if the specialist eventually assumes care of the patient it is still a consultative service when:

 

According to CPT, "A 'consultation' initiated by a patient and/or family, and not requested by a physician," is reported using the confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient). In addition, you can code for these consults when an insurer or other physician seeks a second or third opinion.
 
CPT designates that confirmatory consults are for "rendering an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient, or subsequent hospital care."
 
You can use these codes with new or established patients, when the patient wants a second opinion, and when an insurer requests a specialist's opinion. Confirmatory consults may be provided in any setting. If an insurer requests the consult to determine medical necessity prior to covering a procedure or service, report the appropriate code and append modifier -32 (Mandated services).