Gastroenterology Coding Alert

Question: Our GI attended to a new patient. She said that she was advised by her PCP to see a GI doctor but wasn’t referred to our office by the PCP. She found our office on her own. Will this be considered a consult even though we don’t have direct referral from PCP? 

Colorado Subscriber

Answer: No. This encounter would not be considered as a consultation because the primary care provider (PCP) has not asked your provider for an opinion on the patient’s problem and because of that your GI has no obligation to send a report back to the PCP which constitutes the requirements of consultation coding. 

By definition, according to the CPT® Manual, a consult is “a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.” 

Therefore, to bill a consultation there should be some sort of notation of a request for an opinion by the other provider. Depending on the payer, it doesn’t necessarily have to be a letter from the other provider, but there should at least be a (truthful) note in the record that “Patient is sent by Dr. XYZ for evaluation of abc condition.”

Then, there should be a written report back to the requesting physician explaining the findings and the opinion that was requested. Since the PCP didn’t request your GI’s opinion, I wouldn’t expect to see a typical written report back to the PCP. 

For these reasons, you should not code this as a consultation, but rather, may use a new patient code from among 99201-99205 (New Patient Office or Other Outpatient Services).