Gastroenterology Coding Alert

Reader Question:

Follow Consultation Rules

Published on Sat Mar 01, 2003

Question: If our doctor sends a letter and treatment plan to a referring physician, should our practice bill that as a consult? If he does not send a letter and treatment plan to the physician, should it be a new-patient level for the service? If the referring physician makes an appointment for his patient expecting us to take over the care, how is this billed?

Colorado Subscriber

Answer: According to CPT guidelines, a consultation is a service provided by a physician whose opinion or advice regarding a specific problem is requested by another physician or other appropriate source. "The service needs to be requested by another physician who is coming to the specialist wanting his opinion on that patient's condition," says Lisa Clifford, CPC, owner of the multi-specialty coding firm Clifford Medical Billing Specialists in Naples, Fla. There are a few points to remember when reporting consultations:

The written or verbal request for a consultation must be identified in the patient's records.

The consulting physician must document his opinion in the records, along with services ordered or performed, and communicate this to the referring physician in a written report.

Include the three R's: request, recommend, report.

These criteria must be met in order to bill for a consultation.

Do not confuse consultations with referrals. Areferral is defined as a documented complete transfer of care from one physician to the gastroen-terologist prior to the gastroenterologist's services being rendered. Atransfer of care, or referral, occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance. When your physician does not send a documented response back to the referring physician, you cannot bill for a consultation. Therefore, you would report a new or established patient visit, depending on the situation and setting. These rules also apply when the referring physician calls for an appointment for you to take over the care of the patient.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Linda Parks, MA, CPC, CCP, coding specialist at GI Diagnostics Endoscopy Center in Marietta, Ga.; and Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel.