Gastroenterology Coding Alert

Question: We are a five-physician gastroenterology practice in which one of the physicians specializes in treating hepatitis. Frequently our physicians refer patients to the specialist to confirm a hepatitis diagnosis and to make sure they have diagnosed the correct type of hepatitis (A or B) and plan of treatment. Can we bill for the second opinion even though the specialist is in the same group practice?

Nevada Subscriber

Answer: Second opinion or confirmatory consultations can be billed by your hepatitis specialist, even though the referring gastroenterologist is in the same medical practice, according to Pat Stout, CMC, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn.

Use 99271-99275 (confirmatory consultation for a new or established patient) to report confirmatory consultations, which are defined by CPT as evaluation and management services provided to patients when the consulting physician is aware of the confirmatory nature (e.g., when a second/third opinion is requested or required on the necessity or appropriateness of a previously recommended medical treatment or surgical procedure).

Confirmatory consultations are often requested by the patient or his or her family. The CPT manual states that a consultation initiated by a patient and/or family, and not requested by a physician, may be reported using the codes for a confirmatory consultation or office visits, as appropriate.

These consultations can also be requested by another physician, even one in the same practice. Section 15506 (C) of the Medicare Carriers Manual states that it will pay for a consultation if one physician in a group practice requests a consultation from another physician in the same group practice as long as all of the requirements for use of the CPT consultation codes are met.

Private insurance companies and other third-party payers may require a second opinion to confirm a diagnosis of a chronic condition such as Crohns disease or colitis. In this situation, append modifier -32 (mandated services) to the confirmatory consultation code to indicate that the consultation was requested by a party other than the physician, patient or patient family member.

Traditional CPT requirements for a consultation must still be met with a confirmatory consultation, Stout says. Those requirements include:

A verbal or written request for a consult should be made by a physician or other appropriate source and documented in the patients medical record;

A written report to the requesting physician or other appropriate source that contains the consultants opinion. The opinion also should be documented in the patients medical record.

The physician consultant in a confirmatory consultation is expected to provide an opinion only, according to the CPT manual, which states, Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient or subsequent hospital care. These codes can be used to report E/M services in all site settings (office, hospital or ambulatory setting).

Unlike most CPT evaluation and management (E/M) services, there is no suggested length of time incorporated into the descriptions of these codes. The difference between a level-one confirmatory consultation (99271) and a level-two (99272) depends solely on the complexity of the patients history, examination by the gastroenterologist and the complexity of medical decision making involved.

Many gastroenterologists are unaware that codes for confirmatory consultations exist, Stout says. Instead, they report an established patient office visit code (99211-99215) and lose revenue because the confirmatory consultations are a higher-valued service. A level-three confirmatory con-sultation (99273), which requires a detailed history, detailed examination and medical decision making of low complexity, has a 2001 transitioned non-facility relative value unit (RVU) of 2.36, while a level-four office visit (99214) that requires the same level of history, examination and medical decision making of moderate complexity has a comparable RVU of 2.06.