Gastroenterology Coding Alert

Question: My doctor saw a patient in the hospital and did a low level consult which I would normally code as 99252 since exam & documentation was limited (patient with dementia and rectal bleed). He then stated “colonoscopy” if bleeding continues. This is a new patient to our practice. A colonoscopy was then done on the same day. I am not sure how to code the consult since I will be billing PA Medicare. If I use the 99252, it will be denied since these codes cannot be billed in addition to a procedure on same day. Should I try adding modifier 57 to the consult code?

Michigan Subscriber

Answer:  A consultation can be provided for a new patient or an individual previously seen, if the service meets the requirements for consultation, so “new” isn’t a key concept here; however, CPT^® recognizes only one consultation per admission in the inpatient setting, other services being subsequent hospital care.

If the consultation assessment led to the conclusion that an endoscopic procedure was needed same day, the procedure would be billed without modifier, and the E/M visit with the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) indicating “separately identifiable E/M service.” Some non-Medicare payers still do not recognize the E/M service, which should be appealed; and still can be charged to the patient. Most of the largest national payers have settled class action suits brought by state medical societies in which they have agreed to abide by recognized CPT^® coding and CMS payment conventions.

Note that if the procedure was already planned and the evaluation was just to assess stability for the procedure or provide the administratively required H&P for a facility, no separately identifiable E&M service has been provided, since procedures have an element of E&M work also. In that case, you cannot report a separate E/M in addition to the procedure code and only the procedural code should be reported.