Gastroenterology Coding Alert

Your physician can provide treatment and still claim a consult

When your gastroenterologist accepts responsibility for managing even a portion of a patient's care, you can no longer report a consult code for that patient. Just because your doctor provides some care, however, doesn't mean a transfer of care has occurred.

Here are four tips to help you distinguish between consults and transfer of care.

1. Don't Let Language Fool You

Even if another physician -refers- a patient to your gastroenterologist, you shouldn't assume the visit is a referral or transfer of care. Choosing a standard E/M service code instead of a consult (when the consult is appropriate) will cut into your practice's bottom line because standard E/M visits generally pay less than consults.

-Doctors may tell a patient, -I-m going to refer you to a specialist to see exactly what your problem is.- But they aren't always clear what they mean by -refer.- This can spell trouble for coders trying to choose a correct E/M service code,- says Marvel Hammer, RN, CPC, CHCO, a consultant with MJH Consulting in Denver.

Let the Three R's guide you: Likewise, if the gastroenterologist says he -consulted- with the patient, you shouldn't automatically choose a consult code. CPT defines a -consult- as a very specific service that involves three components:

- a request from another physician for a consult
- an opinion rendered by the consulting physician
- a report on the patient's condition sent by the consulting physician to the requesting doctor.

If the service your GI provides doesn't meet all of these three conditions, you cannot report a consult.

2. Document the Request

If a patient visits your gastroenterologist on his own accord, you must select a standard E/M code to report the service (for example, 99201-99205 for new patients or 99211-99215 for established patients).

-The patient may have a recommendation from the attending doctor to see a physician in a particular specialty group,- says Cindy Parman, CPC, CPC-H, RCC, principal of Coding Strategies Inc. in Powder Springs, Ga., but you cannot bill for a consult if -the -consulting- physician does not note the consult request in the patient documentation.- Even a note stating, for instance, -Dr. Gastro is seeing Mrs. Smith on the recommendation of her primary-care physician, Dr. Jones, because of _____,- can suffice for the request from another healthcare provider.

Bottom line: The attending physician's request (to support the consultation service) must be available as a part of the patient's medical record either mentioned within the visit note or as a separate written note from the requesting healthcare provider.

3. Consult Can Include Care

You may report a consult even if your gastro-enterologist schedules testing or initiates care for the patient--as long as the visit meets the requirements of request, render and report and your physician doesn't assume primary care for the patient's condition.

CPT 2006 makes this point clearly, stating, -A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.-

Further, in July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless if the consulting physician initiates treatment, as long as the visit meets all consultation criteria and no transfer of care occurs.

Fight downcoding: Many insurance companies that see a consult code alongside a treatment or procedure will automatically downcode the claim to a new patient visit. You should appeal these claims as long as you have proof there was no intent to transfer care on that visit, Hammer says.

Coding example: A primary-care physician requests that the gastroenterologist provide a consultation for a patient complaining of abdominal pain. The GI physician meets with the patient, conducts a number of tests and spends some time with the patient discussing possible diagnoses and treatment options. The gastroenterologist prepares a report of her findings and sends them to the requesting physician, then recommends that the patient return soon for a colonoscopy.

In this case, even though the gastroenterologist provided testing and recommended potential treatment options, you may still report a consult. No transfer of care has occurred at this point, and the gastroenterologist has met the requirements of request, render and report

4. Use Standard E/M for Transfer of Care

If the consulting physician accepts primary care for the patient's condition, you must report all subsequent visits related to that condition (that is, all visits that occur after the decision for the transfer of care) using the appropriate-level E/M service code.

-A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance,- explains the Medicare Carriers Manual, section 15506.

In addition, CPT 2006 has added text noting, -If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient's condition(s),- you should report the appropriate E/M services code (instead of a consultation code).

Coding example: Regarding the above example, after the initial consultation, the GI accepts responsibility for diagnosing and treating the patient's GI pain. On subsequent visits, the GI physician will report established patient office visits (99211-99215), as well as any testing or treatment codes, as supported by documentation.