Gastroenterology Coding Alert

Question: A patient we had not previously seen was referred to our office for a sigmoidoscopy. Our gastroenterologist accepted this referral, performed the diagnostic test, and sent the documented results with recommendations back to the referring physician. Shouldn't we code this as a consultation? Virginia Subscriber
Answer: No, this is not a consultation. CPT guidelines define a consultation (99241-99255) 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." 

Key: Your gastroenterologist was not doing the evaluation or management service that entailed giving advice. Nor was he evaluating a complaint. He performed the requested sigmoidoscopy, which is a procedure.��'The patient required no further evaluation; the referring physician had already specified to your gastroenterologist that he wanted a definite medical procedure.

Evaluation or treatment needed as a result of a finding on the exam could also prompt a call to the referring physician to discuss the need for a consultation. Keep in mind: Medicare regulations state that they will pay for a consultation that meets five criteria: a request from a referring physician, the reason for the request, a patient review, a written report sent to the referring physician, and the return of the patient to the referring physician. In this case, the physician had referred the patient for a procedure and did not specifically request an opinion from the gastroenterologist. And if the gastroenterologist took a standard patient history and physical prior to the procedure because you were checking the patient's ability to tolerate the sigmoidoscopy, you cannot separately report these; they're part of the procedure.