Gastroenterology Coding Alert

If your doctor assumes care for the condition, it's a referral

When a gastroenterologist sees a patient at the behest of another physician, coders must know the rules of reporting consultations and referrals, or the office could face frequent denials for these services.

Why? You should report consults with codes from one of four code sets, depending on the situation, while claims for referrals should contain a code from the new patient evaluation and management group, says Kimberly Green, CPC, project coordinator with the University of Pittsburgh Physicians. Read on for some expert advice on differentiating consults from referrals, and how to report each type of encounter. It's Not a Consult Unless Doctor Gives Opinion If your gastroenterologist conducts a visit in order to render an opinion for a requesting physician about a patient's condition - and then the patient returns to the requesting physician for treatment - the visit is usually a consultation, says Laureen Jandroep, OTR, CPC, CCS-P, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. CPT 2005 includes a quadrant of code sets to represent consultations:
   office or other outpatient (99241-99245)
   initial inpatient (99251-99255)
   follow-up inpatient (99261-99263)
   confirmatory (99271-99275).

(Note: For more information on confirmatory consultation codes, please see Check With Providers, Then File Confirmatory Consult Codes later in this issue.)

Who'd refer patients to us? There are many different types of healthcare providers who might want a gastroenterologist to perform a consult: physicians, physician assistants (PAs), oral surgeons, chiropractors, clinical social workers, etc.

Actually, just about any care provider that gets paid by an insurance carrier for its services can get a gastroenterologist to consult.

What makes it a consult? One word: opinion. A consultation is not dependent on whether the gastroenterologist provides treatment. The gastroenterologist may or may not provide treatment during a consult, but she must give her opinion, Jandroep says.

"[Getting the gastroenterologist's opinion] is the intent of the visit when the patient makes the appointment for a consult," Jandroep says.

Good advice: If you are having trouble deciding whether or not a visit qualifies as a consultation, Jandroep advises you ask yourself: "Are they coming in for a consult or to get something 'fixed'?"

Example: Dr. P, a primary-care physician, asks your gastroenterologist for his opinion on one of his patients who is suffering from severe bouts of vomiting and persistent, odd noises from his abdominal area. In an office setting, the gastroenterologist examines the patient's symptoms in the course of a level-two service.

The patient then returns to Dr. P for treatment. The gastroenterologist also sends Dr. P a written report of his findings and any treatments  he rendered.

In this instance, your gastroenterologist provided a consultation. On the [...]