Gastroenterology Coding Alert

Strategies to help you avoid denials Difficulty differentiating consults and referrals won't just land you in a heap of denials, it could be the source of unwanted scrutiny from the feds.
 
When coding referrals and consults, the devil is in the details: How the request is worded, documented and reported must align correctly with CMS guidelines, or else your hard work will earn you nothing. Understand both sides of the equation - what to look for in physician documentation and what codes to use when a consult or referral is delivered - to provide a great service for your practice and your colleagues' practices: clean billing. Know Your Codes CPT includes four types of consultations:
   office or other outpatient (99241-99245)
   initial inpatient (99251-99255)
   follow-up inpatient (99261-99263)
   confirmatory (99271-99275). 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 [...]