Gastroenterology Coding Alert

Question: If another physician calls our gastroenterologist to the emergency department (ED) for a consult on one of our established patients, can we still bill the visit as a consult? The ED physician will bill the ED visit.

Utah Subscriber

Answer: You should bill for consults based on certain criteria. The patient's status as "new" or "established" for your group doesn't affect consult coding.

Therefore, you can bill your physician's care as an initial consult (99241-99245, Office consultation for a new or established patient ...) if it meets the consult criteria and fulfills the documentation requirements. Report "23" as the place of service (Emergency room -- hospital).

Facility note: Although the descriptors for 99241-99245 state, "Office consultation," CPT's introductory note to the section explains why you can use these codes for ED care: "The following codes are used to report consultations provided in the physician's office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home or emergency department."

Check your state: Even with this CPT explanation, some states do not recognize 99241-99245 for an ED consult requested by another physician.

For example, Texas Medicare defines consults as opinion and advice requested by the patient's physician that will impact the patient's treatment plan and care management. Because ED physicians don't have a relationship with the patient and don't form a treatment plan or manage the patient's care, coders must report an outpatient ED visit with 99281-99285 (Emergency department visit for the evaluation and management of a patient ...). You can only report a consult code for these visits if the patient's physician requests a consult in the ED.