Gastroenterology Coding Alert

Documentation hard to track down for 'second opinion' codes

While CPT 2005 does contain codes to represent services the gastroenterologist provides in a confirmatory consultation role, reporting these codes and getting paid is often difficult because of uneven payer policies and rules concerning who ordered the consult.

What Are They? Confirmatory consults are often used for "encounters when a second or third opinion is requested or required by a patient's insurance," says Kimberly Green, CPC, project coordinator with the University of Pittsburgh Physicians. You should also use these codes for consultations requested by a patient or the patient's family.
 
Where Are They? The confirmatory consult code set starts with 99271 (Confirmatory consultation for a new or established patient, which requires these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision-making) and ends with 99275 (... a comprehensive history; a comprehensive examination; and medical decision-making of high complexity). These codes are good for new or established patients who report for confirmatory consults. Why Are They So Hard to Get Paid? When a patient or family member requests a consultation, Medicare and most other insurers will not pay for the encounter. In order to get paid for a confirmatory consult requested or required by an insurer, the gastroenterology office must provide a long paper trail to prove that a confirmatory consult was requested. Getting that much information for a single claim is always difficult, and sometimes impossible.

"I don't use these codes because it is very hard to provide the necessary documentation," Green says.

Wanna try? If you'd like to try your hand at getting confirmatory consults paid, contact each individual provider and ask if it pays on the codes under any circumstances. Then ask them to list those circumstances so you can have a record of the provider's policy.