Gastroenterology Coding Alert

If youre still automatically billing consult codes according to the old CPT adage, Initial visit equals consult, then your gastroenterology practice is waving a red flag to get an auditors attentionespecially with Medicare payers.

Heres the source of the conflict: The CPT manual and the Medicare Carriers Manual (MCM) differ on when the specialist can bill for the initial encounter as a consult (99241-99255).

For example, the CPT guidelines state that the first encounter is considered a consult:

If after a consultation is complete, the physician assumes responsibility for management of a portion or all of the patients condition, then he or she should use the appropriate inpatient hospital consultation code for the initial encounter and then subsequent hospital care codes (not follow-up codes). In the office, the appropriate established patient code should be used.

Under these CPT guidelines, for example, if a primary care physician (PCP) calls a gastroenterologist to the hospital to see a patient with upper GI bleeding to do an EPD, you could bill a consult (99251-99255) for the initial evaluation as well as the upper GI (since the procedure is being performed for diagnostic purposesto allow you to form an opinion to report back to the PCP) and removal of polyp (43250). Likewise, if an internist sent a patient with Crohns disease to the gastroenterologist, you could bill an office consultation (99241-99245) for that initial evaluation and append modifier -25 to show significant separately reportable services.

However, Section 15506 in the MCM has a different position, stating that when the referring physician transfers the responsibility for treatment to the receiving physician at the time of the referral in writing or verbally, the receiving physician may not bill a consult.

For example, under MCM regulation, if a primary care physician asks a gastroenterologist to see a patient for a colonoscopy with polypectomy because of a known polyp, the specialist cannot bill for a consult for the initial encounter. Instead, he or she would have to bill an office visit (99201-99215) or subsequent care (99231-99233).

Some carriers are using the Medicare regulation and are taking great latitude in interpretation of this regulation and redefining consults, says the American Gastroenterological Association (AGA). For example, the association reports these payers are claiming that if the specialist treats the patient or performs a procedure during the initial encounter, it implies that he or she is assuming part of the patients ongoing care.

In fact, Cigna HealthCare in Tennessee went so far as to disallow all consults unless the specialist determined that no treatment was needed.

Note: The Tennessee Medical Association was successful in overturning that interpretation and now consultations may be coded as per the CPT, says the AGC. Thats why its so important to check with your local carrier to not only find out which guideline they are following but also how they are interpreting it.

So When is a Consult a Consult?

Think like an auditor. Ask yourself what the intent of the requesting physician was.

If the internist is asking for advice on how he or shenot the gastroenterologistshould treat the problems, its clearly a consult by both CPT and MCM definition.

Essentially, the attending physician is saying, Take a look and tell me what you think about the problem and give me your opinion, but the patients care for this condition remains with me, says Susan Garrison, MPC, CPC, CPC-H, CPAR, president of the American Association of Professional Coders (AAPC) and a senior manager with Hyatt, Immler, Ott and Blount, a coding and consulting firm in Atlanta, GA.

Here are three tests for determining whether you should bill a consult according to the more restrictive MCM definition:

1. Has the internist already diagnosed a specific GI
problem before he or she asked you to see the patient?

2. Does the internist have the skills to treat the GI problem?

3. Or does he or she expect the specialist to do so?

If the internists intention is for the gastroenterologist to take care of that portion of the patients condition (and the answer to question 2 is no), then an auditor would see even the initial service as a transfer of care, not a consult. Remember, auditors go by the requesting physicians intent to determine if the service is a transfer of care or a consult. Therefore, be very careful in using the word refer in your report of findings. Also, urge the gastroenterologist to talk with their requesting physician and ask them to clarify their requests for consults. For example, the words evaluate and treat would signify to an auditor that the service is not a consult because the intent of the requesting physician is that he or she wants you to treat the patient. If the message the attending physician sends is you take over the care, that is a referral, or transfer of care, she points out.

The AGA uses the example of a primary care physician performing a sigmoidoscopy and finding a polyp. Therefore, when the gastroenterologist first sees the patient prepped and draped at the endoscopy center for a colonoscopy, he or she should not bill a consult.

You cant bill a consult because the polyp has been identified and would never heal without the procedure , i.e. without the skills and expertise of the gastroenterologist, says Susan Callaway-Stradley CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, an accounting firm in Augusta, GA. One of the litmus tests for consults is to ask yourself: Is the treatment beyond the skill of the requesting physician to fix?

If so, you cant safely bill a consult for the initial encounter, at least according to the MCM.

Editors Note: For more coding tips on consults as well as procedures, see the AGA website at http://www.gastro.org.

Frequently Asked Questions About Consults

Question: What if the gastroenterologist does not know who will provide the care until after testing or evaluation?

Answer: Whether to bill a consult does not depend on what the gastroenterologist knows, but what the requesting physician knows as well as what he or she wants the specialist to do (i.e., evaluate or evaluate and treat). Suppose the primary care physician suspects gastroesophageal reflux disease (530.81). Stick to the same rule of thumb: If the requesting physician wants an opinion on how he or she should treat the patients, then it is certainly appropriate to bill a consult. Append modifier -25 (significant, separately identifiable E/M service by same physician on same day of procedure or other service) if the gastroenterologist does a procedure at the same time as the consult. But if the primary care physician wants the specialist to treat the condition, then youll need to bill for an office (99201-99205) or inpatient visit (99221-99223).

Question: When our gastroenterologist is called to see a patient at the hospital by a requesting physician, we dont see that request. All we get is a form completed by our physician that says Consult Report. Should we be billing a consult?

Answer: The biggest mistake a coder can make is to code from the name of a form only. A consulting form does not necessarily a consult make. Neither does a report of findings. Read the consult report carefully. If it says, thank you for referring Ms. Smith for removal of polyp, beware. This verbiage could signify a transfer of care. Read the report carefully to find out exactly whether your physician was giving advice to the requesting doctor on how the requesting physician should provide care or taking over care (i.e., fixing the gastro problem). If it was a procedure only the gastroenterologist could do, then you cant bill a consult. If your physician gave advice only, then you can. Sometimes, you can bill a consult if your physician initiated diagnostic tests or treatmentbut that depends on the intent of the requesting physician. Read between the lines, asking yourself: Did the requesting physician know when the call was made to your office that only a gastroenterologist had the skills to manage this problem? If so, you cannot bill a consult if this patient is a Medicare beneficiary.

Question: So if our physician initiates treatment, how do we make sure carriers wont disallow the consult?

Answer: First, make sure you have met the other criteria of a consult and its clear that the treatment that was started is to be continued by the requesting. Then, caution your doctors to put in writing the communication with the requesting physician as well as his or her response to start treatment. In Medicares definition of a consult, a specialist can initiate care but he cant continue to follow it.

A physician can give a prescription to get the patient started, with instructions for the requesting physician to monitor the medications effectiveness and issue refills.

Question: When is it appropriate to bill follow-up consults?

Answer: Rarely should you bill for codes 99261-99263.

Yet these codes are misused quite often. For example, gastroenterologists sometimes hear the word consult and assume that describes the service rendered after the initial consult. But a follow-up care code should only be billed if the specialist must return to the hospital to complete his original evaluation.

For example, suppose the gastroenterologist cant give a recommendation until after the diagnostics or labs have been performed. Once these are completed, he or she can make a recommendation for treatment. However, the reason for the return must be documented.

Or suppose the gastroenterologist gives the recommendation, completes the consult and walks away from the case. At a later date, because of a failure to achieve success or because of a change in patient condition, the primary care physician asks the gastroenterologist for a new recommendation. In that case you can bill a follow-up consult.

Note: A follow-up consult (99261) pays less than a subsequent hospital visit (99231).