Gastroenterology Coding Alert

Question: Can a transfer of service take place when we conduct a confirmatory consult? How should we code this?

New York Subscriber

Answer: The short answer is "maybe." Technically, the confirmatory consult and the transfer of service are not related. But if a patient elects to have your physician continue to provide service after a confirmatory consult, a transfer of service can take place.
 
Let's define the key elements before we discuss how to code this scenario. According to CPT, a confirmatory consult is "a 'consultation' initiated by a patient and/or family, and not requested by a physician." You report this service using the confirmatory consultation codes 99271-99275. You can also code for these consults when an insurer or other physician seeks a second or third opinion.
 
Confirmatory consult codes can be used with new or established patients when the patient wants a second opinion and when an insurer requests a specialist's opinion. Confirmatory consults may be provided in any setting. If an insurer requests the consult to determine medical necessity prior to covering a procedure or service, report the appropriate code appended with modifier -32 (Mandated services).
 
CPT designates that confirmatory consults are for "rendering an opinion and/or advice only. If, for instance, an initiating physician requests a confirmatory consult from your doctor, she is not referring the patient to your practice for treatment (transferring care); instead, she is looking for an opinion or advice. In this case, she is not even looking for the possibility of initiating treatment as could have been the case if she had asked for a conventional in- or outpatient consultation."
 
A transfer of care commonly happens in one of two ways. The Medicare Carriers Manual (section 15506) defines the most straightforward instance: "A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance."
 
It also occurs when a physician performs a consult for an initiating physician and, after examining the patient, suggests that the consulting physician follow the patient for the problem. Following the patient for the problem will often include subsequent visits, surgical procedures, ongoing treatment and follow-up care. In such a case, the consulting physician's documentation "closes the loop," indicating that the consulting physician performed the consultation at the request of the initiating physician. The documentation should include the consulting physician's report of her medical opinion on the patient's condition and her request to assume care.
 
So, if a physician in your practice provides a confirmatory consult, you use a confirmatory consult code (99271-99275) for the initial consult. If, following the initial confirmatory consult, your physician assumes care of the patent, you code any services subsequent to the opinion with the appropriate level of office visit, established patient, or subsequent hospital care (99211-99215 or 99231-99233).
 
Note: Payers don't reimburse confirmatory consults at as high a rate as regular consults, and most carriers, including Medicare, do not cover them if a patient or family member makes the request. In these cases, you should notify the patient of his payment obligations and provide an advance beneficiary notice to Medicare patients for whom you deliver this service.

 - Clinical and coding expertise for You Be the Coder and Reader Questions provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel; and Linda Parks, MA, CPC, CCP, business office coordinator for GI Diagnostic Endoscopy Center in Atlanta.