Gastroenterology Coding Alert

You'll use specific codes for one, regular E/M codes for the other Latest reports from CMS Comprehensive Error Rate Testing (CERT) program revealed that E/M services -- especially consultations -- lead the list of codes most frequently billed in error. To avoid audit scrutiny, you must know the difference between a referral and consultation. Why? "You bill these services different -- you'd code a referral as a new or established visit code, according to the level and place of service, and you'd code consults from one of two code sets, depending on the situation," says Amy Hilderbrand, CPC, billing specialist at GI Specialist of Georgia in Austell. Doctor's Opinion Means Consult Example: Dr. P, a primary-care physician, asks your gastroenterologist for his opinion on one of his patients who has severe bouts of vomiting and persistent, odd noises from his abdominal area. In an office setting, the gastroenterologist examines the patient's symptoms in the course of a level-four service. The patient then returns to Dr. P for treatment. The gastroenterologist also sends Dr. P a written report of his findings and any treatments he rendered. Solution: In this instance, your gastroenterologist provided a consultation. On the claim, you should: report 99244 (Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the consultation. attach 787.03 (Vomiting alone) to 99244 to account for the patient's vomiting. attach 787.5 (Abnormal bowel sounds) to 99244 to account for the patient's bowel issues. Bottom line: If your gastroenterologist conducts a visit in order to render an opinion for a requesting physician about a patient's condition -- and then the patient returns to the requesting physician for treatment -- the visit is usually a consultation, says Laureen Jandroep, OTR, CPC,-CCS-P, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. CPT 2008 includes two code sets to represent consultations: office or other outpatient (99241-99245) inpatient (99251-99255). What makes it a consult? One word: opinion. A consultation is not dependent on whether the gastroenterologist provides treatment. The gastroenterologist may or may not provide treatment during a consult, but she must give her opinion. Break it down: "This is all about the intent of the visit: opinion or transfer of care," says Jamie McHalek, BS, CPC, client liaison for MediNomics in Shreveport, La. Good advice: If you are having trouble deciding whether or not a visit qualifies as a consultation, ask yourself: "Are they coming in for a consult or to get something fixed?''
Referral Carries Responsibility Example: A patient reports to the office at the request of another physician. After providing [...]