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 [...]