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 physician consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit.

Medicare seems to have redefined transfer of care to mean the complete care of the patient and not just treatment for one particular ailment.

The transmittal goes on to state that a transfer of care occurs when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance.

The document later gives examples that indicate if other routine care continues to be followed by the primary care physician, then no transfer of care has occurred.

If the gastroenterologist does continue treatment of the patient after the consultation, Leineke recommends using the established patient code for subsequent office visits (99211-99215). No further documentation to the primary care physician is necessary.

Three Criteria to Meet for Consultations

In addition, the new Medicare transmittal also lists the following three criteria that need to be met in order to use a consultation code:

1. Specifically, a consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patients medical record.

3. After the consultation is provided, the consultant prepares a written report of his or her findings, which is provided to the requesting physician.

With a relaxed transfer of care requirement, these criteria make proper documentation the key when differentiating a consultation from a new patient visit, notes Scichilone.

The need and request for a consultation must be documented by the primary care physician in the patients medical record, she emphasizes, though a note in the patients chart should suffice.

Then a written report must be sent to the primary care physician. This is one area, Scichilone points out, where Medicare differs from the CPT, which allows the opinion to be communicated verbally through a personal conversation or phone call.

The gastroenterologist is getting paid more by Medicare for the consultation because of the extra work involved in writing the report, explains Scicholone.

The report should include the gastroenterologists opinion and any diagnostic or therapeutic services ordered. Both physicians should keep a copy of the report with the patients records.

These Criteria Dont Constitute a Consult

The transmittal also lists the following as examples that do not satisfy the criteria for consultations:

1. Standing orders in the medical record for
consultations.

2. No order for a consultation.

3. No written report of a consultation.

Referrals as Consultations

The use of the word referral also has many gastroenterologists confused. The referral is commonly interchanged with a consultation.

"If a patient is referred and the gastroenterologist follows the consultation guidelines, then its a consult, according to Leineke. The primary care physician needs to document in the patient record that the patient was sent to the gastroenterologist. Both doctors need to document the follow-up and the results.

Note: To play it safe, it is recommended that you avoid using the term referral when a consultation is the service being requested.

Leineke also adds that if a practice isnt getting reimbursed for consultations, it could be because private insurance carriers have their own rules and dont pay.

For Medicare patients, probably more of their new patient visits can now be coded as consultations as long as the paperwork is there, according to Scicholone. Lots of gastroenterologists truly are consulting, mapping out treatment, and reporting back to the physician. They seem to meet all the guidelines. They just need to document it.

Note: A copy of Medicare Transmittal No. 1644 is available at the American College of Surgeons website at: www.facs.org/about_college/acsdept/socio_dept/
newmedbill.html.