If your doctor assumes care for the condition, it's a referral 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: Get Consult Documentation - 1 Way or Another When you submit a consult claim, include documentation that explains the consultation circumstances. "I recommend that the consultant have the referring office fill out a request-for-consult form and fax it back to your office," Jandroep says. Still Stumped? Try This Trick Coders can also help their consult-identifying cause by thinking of consults as a "circle of care." In a consultation, the requesting physician sends the patient to the gastroenterologist, who provides his opinion. At the end of the visit, the patient returns to the requesting physician for care and the circle is complete. Referrals Draw a Straight Line to Gastro Office While there is a "circle of care" when your gastroenterologist provides a consultation, it looks more like a "direct line of care" when your gastroenterologist gives referral services.
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.
(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 claim, you should:
Even if you don't use consult-request forms, there are ways to note the details of a consult on a claim.
How? One way is having the consulting gastroenterologist include a note on the claim explaining the details of the visit, Green says.
For example, the gastroenterologist billing for the Dr. P consult in the above example could include a note with words to this effect: "I am seeing this patient today at the request of Dr. P for my opinion on the patient's persistent vomiting and abnormal bowel sounds."
"This documentation should either be copied to the requesting physician or be sent in letter form back to the requesting physician. This should provide sufficient evidence that it was a true consultation [because it satisfies] the three R's: Request, Render the Service, and Report Back," Green says.
But if the gastroenterologist takes over the patient's treatment after the initial encounter, the circle is broken and the visit is likely a referral.
What makes it a referral? A referral is the transfer of responsibility for a patient's care from one physician to another. After your gastroenterologist provides a referral service, she is usually the patient's primary physician for treatment of the condition, Jandroep says. "Sometimes, however, the referring physician will only refer part of the care to a gastroenterologist, such as when the patient has a GI operation, but there are still some cardiac issues that another specialist would treat," Jandroep says.
Key point: Unlike consultations, referrals do not have their own code sets. You should report referrals using the E/M codes from the new patient code set, Green says.
Example: A patient reports to the office at the request of another physician. After providing a level-four service, the gastroenterologist decides that the patient may have one of several esophageal disorders. The gastroenterologist then schedules the patient for a follow-up visit for more tests and potential treatments.
In this instance, the gastroenterologist took over care of the patient's esophageal problems, so the service is a referral. On the claim, you should report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the referral.
Proving that a visit was a consultation might be a tad more challenging than reporting a referral. To alleviate this problem, Jandroep recommends that you get some proof of the request from the requesting office for referrals as well.
"It is professional courtesy to send a [request form] even for a referral," she says.