Gastroenterology Coding Alert

 Question: A patient we had not previously seen was referred to our office for a sigmoidoscopy. Our gastroen-terologist accepted this referral, performed the diagnostic test, and sent the documented results with recommendations back to the referring physician. Shouldn't we code this as a consultation?

                                                                                       Virginia Subscriber

 Answer: No, this is not a consultation. Refer to your CPT guidelines, which define a consultation (99241-99263) as a "type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source."
    
At first, it might appear that this as a consultation; however, the key here is that your gastroenterologist was not doing the evaluation or management service that entailed giving advice. The gastroenterologist was not evaluating a complaint, says Beth Mosley, accounts representative at Cary Gastroenterological Associates in North Carolina. He performed the requested sigmoi-doscopy, which is a procedure. The patient required no further evaluation; the referring physician had already specified to your gastroenterologist that he wanted a definite medical procedure.

This opinion is reinforced by Michael Weinstein, MD, a gastroenterologist in Washington, D.C. "I would not recommend submitting a claim for anything other than the procedure if it is a routine exam," he says. Evaluation or treatment needed as a result of a finding on the exam could also prompt a call to the referring physician to discuss the need for a consultation.

Medicare regulations state that they will pay for a consultation that meets three criteria: a request from a referring physician, a patient review, and a written report sent back to the referring physician. In this case, the physician had referred the patient for a procedure and did not specifically request an opinion from the gastroenterologist. And if you took a standard patient history and physical prior to the procedure because you were checking the patient's ability to tolerate the sigmoidoscopy, you cannot separately report these; they're part of the procedure.

But suppose that during the preprocedural physical, the gastroenterologist finds that the patient needs some additional evaluation. In this case, you would probably notify the referring physician that a consultation is now in order. If the referring physician concurs that a consult is needed, the gastroenterologist can perform the appropriate level of E/M consultative service (99241-99245) and can also perform the sigmoidoscopy if needed, Weinstein says. You can bill both services using modifier -25 on the E/M service. Linda Parks, MA, CPC, CCP, lead coder at Atlanta Gastroenterology Associates, concurs, stating that she would not submit an E/M for this visit unless the physician had spoken with the referring physician and it was decided at that point that a consult was needed.