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. [...]