Gastroenterology Coding Alert

Question: My gastroenterologist recently saw a patient at the request of the primary-care physician. The patient complained of severe fatigue and rapid weight loss and showed signs of jaundice. After performing a comprehensive history and exam with moderate medical decision making, the physician diagnosed acute hepatitis C without hepatic coma. My gastroenterologist recorded his findings and provided a report to the requesting physician. How should I report this visit?

Florida Subscriber

Answer: You should report 99244 (Office consultation for a new or established patient ... requires these three components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity) for the initial consultation.

Keep in mind: Be sure you have met all the documentation requirements for a consult visit before billing it as such. Documentation requirements for consultations vary by payer, but experts say your consultation documentation should at least include evidence of the following "R's":

• The name of the Requesting provider.

• The Reason for the consultation ( "...evaluation and recommendation of...")

• A Review of any records sent by the requesting provider.

• Documentation of the consulting providers' impression and Recommendations for treatment.

• A separate written Report to the requesting provider.

If you cannot meet the requirements to bill a consultation code, you will have to report a lower-paying outpatient E/M service -- for example, 99201-99205 (Office visit for the evaluation and management of a new patient...) for a new patient or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) for an established patient.

Pitfall: If you are reporting this service to Medicare, you should not use the consultation code. As of Jan. 1, Medicare carriers -- and several private payers as well -- are not recognizing the consultation codes. Instead, you'll need to use the appropriate outpatient E/M code (99201-99215). Check with your individual payers to see how you should report consultation services this year.

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta; and Marcella Bucknam, CPC, CCSP, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.