Gastroenterology Coding Alert

Question: Frequently, a primary care physician will schedule a patient with our gastroenterologist to perform a colonoscopy in the hospital. He will often schedule a meeting with the patient after the colonoscopy to discuss findings and treatment. One of our coders feels that this office visit should be coded as a consultation because the primary care physician asked for an opinion or advice regarding treatment. Is this correct?

Louisiana Subscriber

Answer: From the information you provided, it appears that there was not a specific request from the primary care physician (PCP) asking for the gastroenterologists opinion or advice regarding treatment, so this does not qualify as a consultation. If you intend to report the visit, it should probably be coded as an established patient office visit (99211-99215).

A consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source, according the Principles of CPT Coding, which is published by the AMA. For an E/M service to be a consultation, the Three Rs rule must be met:

Request A verbal or written request for a consultation should be made by a physician or other appropriate source and documented in the patients medical record;

Review An exam must be performed and documented; and

Report A written report must be made to the requesting physician or other appropriate source from the gastroenterologist containing his or her opinion. The opinion should also be documented in the patients medical record.

It does not appear that there was a verbal or written request for a consultation from the PCP in your situation. The PCP simply wanted an endoscopy performed. It is not uncommon to send a patient to a gastroenterologist for an endoscopy only. The gastroenterologist should give the results to the PCP, and let him or her take it from there.

To be considered a consult, there must be clear communication from the PCP before the procedure is performed that the gastroenterologists advice and opinion are being requested. You have to know the intent of the PCP before the visit can be correctly coded. As mentioned above, that communication must be documented in the patients medical record.