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Gastroenterology Coding Alert

Focus on E/M:

Draw the Line Between Referrals and Consultations

Published on Sun May 18, 2008

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 a level-two service, the gastroenterologist decides that the patient has increased risk for colon cancer and no other active health problems that will conflict with any endoscopic procedure or the administration of conscious sedation. The gastroenterologist then schedules the patient for a follow-up visit for a colonoscopy.

    In this instance, the gastroenterologist took over care of the patient for a specific treatment, so the service is a referral. On the claim, you should report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) for the referral.

    What makes it a referral? A referral is the transfer of responsibility for a patient's care from one physician to another. After your gastroenterologist provides a referral service, she is usually the patient's primary physician for treatment of the condition.

    Good practice: You may want to send the results of testing or treatment to the patient's primary-care physician. Remember, sending results to the primary-care physician does not make the service a consultation.

    Key point: Unlike consultations, referrals do not have their own code sets. You should report referrals using the E/M codes from the new outpatient visit code set, if the GI has not provided professional services to the patient within the previous three years.

    Get Into a Routine

    You should have a routine when it comes to determining whether a visit qualifies as a consultation or a referral.

    Check this out: "We have a router that the doctor fills out immediately after the patient is seen," says Linh Nguyen, medical coder for Gastroenterology Associates in Evansville, Ind. "He determines what level of service to charge, and we have someone who enters the codes into our system. She verifies that the visit is in fact a consultation by viewing the appointment notes in our system.

    "If the notes do not list a referring doctor, then she pulls the chart and checks if the chart includes a request for consultation and report. If not, she sends it back to the physician for him to circle the level of service under the new patient visit codes."

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