Gastroenterology Coding Alert

Gastroenterologists often bill for new or established patient office visits (99201-99215) when they are asked to provide a second or third opinion concerning a recommended medical treatment or surgical procedure. But these evaluation and management (E/M) sessions actually should be coded as confirmatory consultations (99271-99275). Not only is it correct billing, but they have a higher relative value unit (RVU) and can increase the physicians level of reimbursement.

The traditional standard for determining an office or outpatient consultation is the three Rs:

1. a reason for the consultation,
2. a request for the consult from the primary-care physician, and
3. a written report on the findings of the evaluation issued by the consulting physician to the primary care physician.

The reason and request for a consultation are documented in the patients medical record by the physician requesting the consult, and the report from the consulting physician should be in written form with a copy placed in the patients medical record.

Documentation Requirements Unclear

Both CPT 2000 and Medicare define a confirmatory consultation as services provided to patients when the consulting physician is aware of the confirmatory nature of the opinion sought. Medicares definition goes on to state that they are requested by the patient, family, or third party. Because these kinds of consultations generally are initiated by the patient or patients family, there may not be a request for the consult from a physician to be documented in the patients medical file, says Janet Leineke, CCS, CPC-H, senior outpatient consultant for Laguna Medical Systems, a health information management consulting, outsourcing and education services company in San Clemente, Calif. Its also unclear as to whether a report on the findings of the evaluation needs to be written and to whom it should be issued.

Neither CPT nor Medicare says that any type of report has to be issued in these situations, notes Leineke. The gastroenterologist will be giving an opinion to the patient, but theres nothing that says it has to be in writing, she adds.

One way around this documentation dilemma is to issue a report to the patients primary care physician, regardless of whether he or she was involved in setting up the confirmatory consultation. Thats the standard procedure at Atlanta Gastroenterology Associates, explains Linda Parks, MA, CPC, lead coder of the 21-physician practice.

Different From Office/Outpatient Consult

Another difference with confirmatory consultations is that the same code is used regardless of whether the consult takes place in an office, hospital or ambulatory setting, Leineke points out.

In addition, CPT does not establish typical times for the length of a particular level of confirmatory consultation as it has for other types of E/M services. The difference between a level one confirmatory consultation (99271) and a level two (99272) depends solely on the complexity of the patients history, the examination by the gastroenterologist, and his or her level of medical decision-making, says Parks.

Note: Private insurance companies and other third parties may require a second opinion via a confirmatory consultation. This often is done to confirm a diagnosis of conditions such as Crohns disease or colitis, notes Parks. Modifier -32 (mandated services) should be added to the code for these required consultations, which generally will be reimbursed by private insurance companies, but not by Medicare.

Physician-Initiated Second Opinions

In Parks practice many of the confirmatory consultations are initiated by physicians who send their patients to her practice to confirm a diagnosis. For example, an internist may send a patient to the practices gastroenterologist to confirm an ulcer diagnosis.

Because these consultations are initiated by a physician and not the patient, family or a third party, Leineke questions why these are coded as confirmatory consultations and not as standard office consultations, which have an even higher relative value unit. She highlights a section in the CPT on consultations in general that states a consultation initiated by a patient and/or family, and not requested by a physician, may be reported using the codes for confirmatory consultation or office visits, as appropriate.

The CPT section on confirmatory consultations also says, however, that codes 99271-99275 should be used when a physician consultant providing a confirmatory con-sultation is expected to provide an opinion or advice only. In this case, thats all the specialist is doing, Parks says.

A second reason why Parks does not bill these specialist evaluations as a standard office consultation (99241-99245) is that the patient often already has been billed for one office consultation and wont be reimbursed for any others by Medicare.

Usually the patient has already been referred to us by a primary care physician for a consultation, and our local Medicare payer will reimburse a practice once every three years for an office consultation for the same ailment.

Editors Note: Not every local Medicare payer has this limitation on the number of consultations allowed per practice. Therefore, you should check with your local Medicare carrier to determine its policy.

Better Reimbursement Than an Office Visit

Gastroenterologists who code these evaluations as office visits are undercutting themselves and could be getting paid more, Parks says

Because local Medicare and private insurers may have specific documentation and other requirements
for confirmatory consultations, gastroenterologists should check with their local payers to get specific coding instructions.