Gastroenterology Coding Alert

Nearly a year after Medicare tried to clarify its definition of consultations, many gastroenterologists are still having difficulty deciding whether the evaluation and management (E/M) service that they render to a patient in the emergency department (ED) is a consultation. The sticking point seems to be how to determine whether the services provided by the gastroenterologist represent a transfer of care.

One of the reasons this is such a problem with all physicians is that a consultation among physicians is different than the CPT definition of a consultation, says Charla Prillaman, CPC, a senior coding consultant for Webster, Rogers & Co., a multispecialty healthcare consulting firm in Florence, S.C. For some physicians, a consultation means help me out with this, but the CPT definition requires that a certain kind of service takes place where the original physician retains some care of the patient.

Three Rs Must Be Met

When talking about consultations, coding professionals frequently refer to the three Rs that must be met, says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J.

1. The request: The ED physician must make a request in writing to the gastroenterologist, soliciting his or her opinion on the patients condition. This request also should include the reason or medical necessity behind the consultation. Medicare guidelines state that a simple entry in the emergency departments common medical record for the patient is adequate.

2. The review: The gastroenterologist must review the patients condition, documenting the three components in the patients medical record. All three of these key components of an E/M visit (history, examination and medical decision-making). These will be considered when determining the level of consultation.

3. The report: After the review of the patients condition, the gastroenterologist must issue a written report to the ED physician about the patients condition. A copy of the report should be filed in the patients medical record.

No Consultation if Care of Patient Is Transferred

Having met these three requirements, however, does not guarantee that the E/M service was a consultation. Many times the gastroenterologist will meet all these requirements, says Brink. But if the gastroenterologist ends up taking over the care of the patient, then you probably dont have a consultation.

CPT doesnt address the issue of transfer of care during a consultation except to state, A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.

Medicare, in an effort to clarify its policy on consultations, revised its instructions to carriers in August 1999 by stating, Payment may be made regardless of treatment initiation unless a transfer of care occurs. The instructions continue, A transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance.

Brink believes that many gastroenterologists may report a consultation code incorrectly for an E/M service in the ED. Many gastroenterologists tend to look at all initial encounters with new patients, including those in the emergency department, as consultations, she explains. But the question that needs to be asked is whether the gastroenterologist is taking over care of the patient at the request of the emergency department physician or is he or she only rendering an opinion for the ED physician, who will continue to oversee the patients care.

Transfer Needs to Occur When Request Is Made

Some coding professionals believe that the focus should be on whether the transfer of care occurs at the time of the request by the referring physician. Even if the gastroenterologist eventually does take over care of the patient, a consultation may still occur, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a member of the American Medical Associations (AMA) CPT advisory panel.

When the request is made by the emergency department physician, it is unknown whether the gastroenterologist will take over the patients care, Weinstein continues. A common complaint like abdominal pain could be a lot of things. Thats why its a consultation because until its over, you dont know what the opinion will be.

Look at Role ED Physician Continues to Play

When determining whether a visit is a consultation, look at the role the ED physician continues to play in the treatment of the patient. The gastroenterologist may initiate care of the patient during a consultation by prescribing medication for the patient or ordering x-rays, but the emergency department physician needs to follow-up with the patient after the gastroenterologist has performed the consultation, says Brink.

Prillaman also believes that some follow-up by the ED physician is necessary for the gastroenterologists visit to be a consultation. A complete transfer of care will happen more in the emergency department than any other place, she notes. An internist may refer a patient to a gastroenterologist for a consultation, but the internist will continue to treat the patients diabetes and hypertension. An emergency department physician is more likely to think, Lets call in a gastroenterologist and have him or her decide what to do.

If the gastroenterologist initiates treatment by giving the patient some medication, tells the emergency department physician what was done, and then the ED physician meets with the patient before discharging him or her, thats probably a consultation, Prillaman concludes. If the gastroenterologist handles the patient discharge, thats a good sign that a transfer of care has occurred.

If the E/M encounter is not a consultation, then the gastroenterologist should bill either an ED visit (99281-99285) or an outpatient/office visit (99201-99215) depending on whether the payer is Medicare or a commercial insurance company. Ive seen gastroenterologists use both types of codes in emergency department situations, although the emergency department visits have a higher reimbursement than the established patient outpatient/office visits, says Prillaman.

Medicare Allows Billing of ED Codes

Medicare allows gastroenterologists who arent ED physicians to bill ED codes. Section 15507(A) of the Medicare Carriers Manual states that any physician seeing a patient registered in the emergency department may use the emergency department codes, regardless of whether the physician is assigned to that department.

Medicare also allows these codes to be used to report nonemergency services as long as the patient is seen in the ED for an unanticipated service. But if the gastroenterologist asks a patient to meet him or her in the emergency department because it is more convenient than meeting at the gastroenterologists office and the patient is never registered in the emergency department, the gastroenterologist should report an office/outpatient visit code.

Some Payers May Require Office/Outpatient Codes

CPT coding guidelines, which are often followed by commercial insurance companies, differ slightly from Medicares when it comes to ED visits. Two publications from the AMA, Principles of CPT Coding and The CPT Companion, state that the gastroenterologist should only report an emergency department code if he or she is the sole physician to see the patient in the ED. If an ED physician sees the patient and reports an emergency department visit, the gastroenterologist should report an office/outpatient code.

Finally, Prillaman notes that all three key components of an E/M visit must be considered when determining the level of an emergency department visit, as well as a new patient office/outpatient visit. An established patient office/outpatient visit only requires consideration of two of the three key components.