Gastroenterology Coding Alert

Question: My gastroenterologist read an article on the 10 most common errors discovered in an audit. One of the errors listed was billing every referral as a consultation. I believe most of our referrals are going to be consultations because our gastroenterologist does not assume care of the patients. He takes the referral, performs the diagnostic endoscopy or test, and then sends it back to the referring physician with recommendations based on his findings. He follows all guidelines as far as documentation and correspondence with the referring physician. Is this correct?

Alabama Subscriber

 
Answer: A consultation (99241-99263) is an E/M service provided by a physician whose opinion and advice are requested by another physician or appropriate source, based on the CPT definition. One of the difficulties in answering your question is that it seems to indicate that the patient was referred for an endoscopic procedure or test and not an E/M service.
 
Many gastroenterologists allow patients to be directly referred by other physicians for procedures. In most of these cases, the patient arrives to see the gastroenterologist and is prepared to have the procedure recommended by the referring physician on that day. Because the referring physician has already given a clear medical indication for the procedure to be performed, the gastroenterologist need not perform any further evaluation of the patient except for the standard preprocedure history and physical (which is not separately reportable).
 
In those situations, therefore, when the patient is referred for a procedure, it is inappropriate to bill separately for a consultation or any other E/M service. The gastroenterologist should bill for the procedure and report to the referring physician a summary of the findings from the procedure and any recommendations based on those finding. If, after the preprocedure history and physical, the gastroenterologist determines that the patient requires a more in-depth evaluation, the referring physician should be contacted first to confirm a request for a consultation service.
 
If the referring physician wants the gastroenterologist to see the patient for an E/M service, Medicare has directed its carriers to pay for a consultation when the three criteria (request from a referring physician, review of patient, report back to referring physician) for a consultation have been met.
 
A consultation is not always completed during the initial visit, and the consulting physician may initiate diagnostic and/or therapeutic services, such an endoscopy, before reporting to the referring physician. In that situation, it is possible that both a consultation and a procedure could be separately billed.
 
If the referring physician transfers the responsibility for treatment to your gastroenterologist at the time of the referral in writing or verbally, a new patient or established patient office visit (99201-99215) should be reported instead of a consultation code if the encounter took place in an office setting. If the encounter took place in a hospital setting and there was a transfer of the responsibility for treatment, your gastroenterologist should bill the appropriate subsequent hospital visit code (99231-99233).