Gastroenterology Coding Alert

When hepatitis C patients are referred to us by a primary care physician, is the first visit a consultation or a new patient visit? asks Judy Basar, a coding and documentation specialist with Focus Health Services, a multi-specialty practice with 45 physicians, including gastroenterologists, in Englewood, CO. In situations like these, gastroenterologists are often confused over whether to bill the first visit as an initial office/outpatient consultation (99241-99245) or as a new patient office visit (99201-99205).

There is a financial incentive for a gastroenterology practice to bill for a consultation, which has a higher allowable reimbursement. The difference between a level 3 consultation (99243) and a level 3 new patient office visit (99203) is about $20, estimates Janet Leineke, CCS, CPC-H, and senior outpatient consultant for Laguna Medical Systems, a company headquartered in San Clemente, CA, that offers health information management consulting, outsourcing and education services.

On the other hand, every visit should not automatically be labeled a consultation because the Office of the
Inspector General (OIG) is starting to really review
consultation claims, she cautions. Any overcoding could be considered fraud.

So understanding the difference between a patient being sent to you for an opinion or transferred to you to assume their care is more important than ever.

Theres always controversy regarding the definition of a consultation and under what circumstances you can bill for one, says Rita Scichilone, MHSA, RRA, CCS, CCS-P, coding practice manager for the American Health Information Management Association (AHIMA), a Chicago-based organization that represents more than 38,000 specially educated health information management professionals.

The CPT and Medicare are a little bit at odds, she adds. A recent update to the Medicare Carriers Manual (MCM, Transmittal No. 1644, August 1999) broadens the definition of what constitutes a consultation, making it
easier for gastroenterologists to bill for an increased level of reimbursement.

Transfer of Care Stipulation

The biggest change in the new Medicare instructions is the redefinition of what constitutes a transfer of care. In the past, any initiation of treatment by the gastroenterologist was considered transfer of care, and any transfer of care meant that the evaluation had to be billed as a new patient visit rather than a consultation. If there was any expectation that the gastroenterologist would continue to treat those patients, say, for hepatitis, then that was considered to be a transfer of care.

Under the new Medicare instructions, the gastroenterologist can begin treatment and still bill for a consultation. The transmittal states that Medicare will pay for an initial consultation if all the criteria for a consultation are satisfied. Payment may be made regardless of treatment initiation unless a transfer of care occurs ... A [...]