Gastroenterology Coding Alert

Question: Apatient was last seen by our PA on 10/21/11 for diarrhea and abdominal pain. The patient came back on 1/28/14 and saw the doctor for possible gastric outlet obstruction and other gastric issues. I think the patient should be coded as established since it hasn’t been 3 years since last visit to our office. My doctor thinks it should be consult because patient was referred for evaluation of a new problem. Which one is correct and why?

Tennessee Subscriber

Answer: As you have pointed out, as three years have not elapsed since the patient saw one of your providers, you are right in identifying the patient to be an established patient.

But consultation codes can be used for new or established patients. Depending on the documentation (request, render, return report), your doctor may be right about billing a consultation. If the patient is being seen for a new set of symptoms and if another provider is seeking your provider’s opinion on the patient’s problem and then sends a return report back to the requesting provider (see consultation requirements) a consult code may be appropriate.

Codes 99241-99245 are for “Office consultation for a new or established patient, which requires these 3 key components ...” As indicated in the code descriptor, you can use these codes even if the patient has been seen in the past three years.

Reminder: One thing to you need to ensure prior to billing out consultation codes is to check and make sure the payer you are billing to still accepts consultation codes. This is necessary to avoid denial as some payers, such as Medicare, no longer accept these consultation codes. For a Medicare patient you would need to use the appropriate established visit code because the patient was seen within the past three years. But, if the payer that you are billing for accepts these consultation codes, you can bill the appropriate level consultation code for this visit and not an established office code.