Gastroenterology Coding Alert

Question: My provider looked to another provider for their opinion on one of our patient’s ulcers. Do both physicians need to document the consultation?

Pennsylvania Subscriber

Answer: Not every service can be performed at your office, which is one main reason some services are ordered or referred. Whether your GI specialist is the physician performing the service or the one ordering it from someone else, both parties need to maintain medical records. The reason why comes down to medical necessity.

Sometimes, a payer will request the medical records associated with a particular service. The payer needs the records from both the ordering and the rendering providers to confirm medical necessity. The payer will deny the claim if there is not sufficient evidence from all parties involved. Not only do both parties need to submit their documentation of the service(s) provided, but the documentation also needs to show consistency and continuity. When documentation is submitted by both the performing and the ordering provider, and that documentation conflicts, the payer is likely to deny the claim.