Gastroenterology Coding Alert

Thinking that they might be missing out on some extra reimbursement, several gastroenterologists have asked Gastroenterology Coding Alert about the proper use of followup inpatient consultation codes (99261-99263) and whether those codes should be used instead of subsequent hospital care codes (99231-99233).

Although there are specific instances when the followup inpatient consultation codes should be used, gastroenterologists who are tempted to substitute these codes for a subsequent care code should be aware that followup consults have a lower level of reimbursement.

Gastroenterologists often dont have a clear understanding of why or when to use these codes, says Pat Stout, CMT, CPC, an independent gastroenterology coding consultant from Knoxville, Tenn.

Defining Subsequent Consultations

A followup inpatient consultation code may be reported when a gastroenterologist is called by another physician to perform a subsequent consultation on a patient. For example, a patient who is admitted to the hospital because of uncontrolled diabetes develops unexplained jaundice, Stout says. After examining the patient and running some tests, the admitting physician calls a gastroenterologist for a consultation. After the gastroenterologist conducts his or her examination, an endoscopic retrograde cholangiopancreatography (ERCP) is performed, but no stones are found that might be causing the patients jaundice. The patients symptoms and jaundice appear to improve, and the gastroenterologist signs off on the patient. Several days later the patient, who still has uncontrolled diabetes, becomes jaundiced again, and his or her blood chemistries are elevated. Again, the attending physician calls the gastroenterologist for a consultation, which should then be billed as a followup consultation.

Defining a Complete Initial Consult

The followup consultation codes can also be used to complete an initial consultation with a patient, according to Stephanie Jones, CPC, a multispecialty coding consultant in Boca Rotan, Fla. These codes were designed to be used when a physician is asked to come in for an opinion, she says. The physician takes a history, does a physical examination and some medical decision-making, such as ordering a test, but cant render an opinion until the results of the test are back.

If no opinion can be rendered, Jones continues, the physician needs to note in the patients shared medical record that a followup is required at this time.

The gastroenterologist cannot use the followup consultation as a session to review the test results with the patient. Two of the three key components of an evaluation and management (E/M) service must also occur and be documented in the patients medical record for this to be considered a consultation. The gastroenterologist must be face-to-face with the patient and take a separate history, and perform a separate physical examination and medical decision-making before this can be billed as a followup consultation, Jones explains.

Jones also cautions that the followup consultation cannot be reported on the same day as the initial consultation. Only one E/M code can be billed per day for a particular patient by a gastroenterologist, she says.

Dont Bill a Followup After an Endoscopy

Stout says it is not appropriate for gastroenterologists to report a followup consultation every time they meet with a patient after an endoscopic procedure. Gastroenterologists could argue that they have to perform an endoscopy to render an opinion, she says. But gastroenterologists should avoid billing a followup consultation for every patient visit following an endoscopy unless there is a separate history, examination and medical decision-making to document.

The best time for a gastroenterologist to use these codes is when he or she has signed off on a patient and is then asked to come back for another consultation by the attending physician, Stout says.

Followups Must Meet Three Rs

Just like any other consultation, these codes must meet the following CPT and Medicare requirements for a consultation, commonly referred to as the three Rs:

The Request: The attending physician must make a request in writing to the gastroenterologist, soliciting his or her opinion on the patients condition. This request should also explain why the consultation is requested. A simple entry noting the request in the patients shared medical record is usually sufficient.

The Review: The gastroenterologist must review the patients condition. The documentation in the patients medical record should indicate the history-taking, examination and medical decision-making performed by the gastroenterologist. Only two of these key components of an E/M visit (interval history, examination and medical decision-making) must be considered to determine the level of consultation.

The Report: After the review of the patients condition, the gastroenterologist must render an opinion or report back to the attending physician. This report should be documented in the patients shared medical record.

Only Two of Three Key Components Considered

There are two so-called breaks that come with followup consultation codes. The first is that only two of the three key components of an E/M service (history, examination, and medical decision-making) need to be considered by the gastroenterologist when determining the level of consultation. The other is that the gastroenterologist only has to take an interval, or limited, patient history. Only the history of present illness and the review of systems have to be considered, Jones says.

Unlike most consultations, the followup consultation codes include a statement about the status of the patient in their descriptions. The descriptor for 99262 states, Usually the patient is responding inadequately to therapy or has developed a minor complication. These status indicators should be considered as contributing factors that will often already be reflected in the history, examination and medical decision-making. In addition, it is unlikely that many gastroenterologists will be reporting a level-one (99261) followup consultation.

Stout also adds that gastroenterologists should use a diagnosis code that indicates the problem they were called in to look at, not the problem the attending physician is treating. In the extended scenario previously cited, for example, the gastroenterologist should report a diagnosis code for jaundice (782.4, jaundice, unspecified, not of newborn), and not one for diabetes.

Dont Substitute Consults for Care

Although a consultation code often has a higher level of reimbursement than a patient visit of the same level, the reimbursement for a followup consultation is not higher than for a similar-level subsequent hospital care visit.

The relative value units for followup consultations do not accurately reflect the actual amount of work provided, Stout says. I question the rationale used in determining those values considering the level of work associated with consultative services.

Because of the difference in reimbursement levels, gastroenterologists need to avoid the mistake of reporting a followup consultation when they should really be reporting a subsequent care code, which often happens when a consulting gastroenterologist provides treatment. According to CPT, If subsequent to the completion of a consultation, the consultant assumes responsibility for the management of a portion or all of the patients condition(s), the followup consultation codes should not be used. In the hospital setting, the consulting physician should use the appropriate inpatient hospital care consultation code for the initial encounter and then subsequent hospital care codes (not followup consultation codes).

In the scenario with the patient who has both jaundice and uncontrolled diabetes, for example, the gastroenterologist who performs the ERCP will probably monitor that patients condition for a few days after the procedure, Stout explains. Those E/M visits related to the ERCP can be billed as subsequent care visits, she says.

Coding Consults and Care Visits

Many gastroenterologists want to bill followup consultations instead of subsequent hospital care codes because they assume that the followup consults like many other consultative services have a higher level of reimbursement. The following examples indicate that the subsequent care codes have higher levels of reimbursement for a similar level of history, examination and medical decision-making.

Level 1 Visit Problem-focused interval history, problem-focused examination, straightforward or low-complexity medical decision-making. Patient status is stable, recovering or improving.

Followup consultation code: 99261
Typical time spent with patient: 10 minutes
Relative value unit: .69

Subsequent hospital care code: 99231
Typical time spent with patient: 15 minutes
Relative value unit: .94

Level 2 Visit Expanded-problem focused interval history, expanded problem-focused examination, medical decision-making of moderate complexity. Patient is responding inadequately to therapy, but developed minor complication.

Followup consultation code: 99262
Typical time spent with patient: 20 minutes
Relative value unit: 1.28

Subsequent hospital care code: 99232
Typical time spent with patient: 25 minutes
Relative value unit: 1.50

Level 3 Visit Detailed interval history, detailed examination, medical decision-making of high complexity. Patient is unstable or has developed a significant complication or new problem.

Followup consultation code: 99263
Typical time spent with patient: 30 minutes
Relative value unit: 1.88

Subsequent hospital care code: 99233
Typical time spent with patient: 35 minutes
Relative value unit: 2.33