Gastroenterology Coding Alert

Question: While on-call in the emergency department (ED), our gastroenterologist saw a 30-year-old for rectal bleeding. The gastroenterologist wants to bill this as 99243 (Office consultation for a new or established patient, which requires these three key components: detailed history, detailed examination, medical decision-making of low complexity). We thought we could not use 99241-99245 outside of office
visits. How should we report this procedure?

South Carolina Subscriber
 

Answer: Many coders believe that they must use codes 99241-99245 only for office visits, but, in fact, the codes also apply to true consultations done in an ED or any outpatient setting.
 
The CPT manual states that these 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, custodial care, or emergency department." 
 
You must determine if this visit is actually a consultation and not a transfer of care. A consultation must meet certain requirements; an important one is that the attending emergency physician must request an opinion from your gastroenterologist, while still assuming care of the patient.
 
But if the attending physician transfers care of the patient over to the gastroenterologist, you cannot bill for a consultation.
 
Once you determine that this is a consultation, even though the ED physician also sees the patient, you should report the ED service using 99281-99285 (Emergency department visit for the evaluation and management of a patient ...).
 
Check your carrier's policy on this situation, because many decline ED codes from two physicians seeing the same patient. Or your carrier may require that you apply the appropriate new or established patient code (99201-99215, Office or other outpatient visit for the evaluation and management of a patient ...) instead.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Marylou Masters, CPC, billing representative at the University of North Texas Health Science Center; Linda Parks, MA, CPC, CCP, lead coder at Atlanta Gastroenterology Associates; and Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.