Gastroenterology Coding Alert

After a consultation, gastroenterologists frequently may recommend immediately doing a procedure such as a colonoscopy. But they may have difficulty getting reimbursed for both the consultation and the procedure performed on the same day. Coding properly and adhering to the patients health plan guidelines should alleviate reimbursement headaches.

A gastroenterologist gets called to the emergency room to do a consultation on a patient with rectal bleeding. Once he or she evaluates the patient, the physician decides to do a procedure like a colonoscopy, says Angie Burns, who manages the billing department for Dr. Richard Kuritzkes practice in Burbank, CA. The problem is that usually theres no reimbursement for the
consultation, even though its not part of the procedure.

But this isnt always the case. Although some local Medicare offices and private insurance companies have stated that they will not reimburse for both a consultation and a procedure that are performed on the same day, others will payprovided the health plan coverage conditions are met, and the coding is reported correctly.

Documentation Is the Key

First, coders must determine whether the gastroenterologist performed a consultation (99241-99245) or a visit with a new patient (99201-99215). Even though the evaluation took place in an emergency room, the three basic criteria for a consultation still apply, according to Rita Scichilone, MHSA, RRA, CCS, CCS-P, medical coding practice manager for the American Health Information Management Association, a Chicago-based organization representing more than 38,000 health information management professionals.

The emergency room is no different than any other outpatient setting, she says. A consultation still has
to have the three Rs: a request from an appropriate source, a reason for the consultation, and a written report from the consulting gastroenterologist back to the requesting physician.

The Request: In this case, the requesting physician is an emergency room doctor whose request for a consultation must be recorded in the patients medical record. Recent Medicare guidelines state that a simple entry in the emergency departments common medical record for the patient is adequate.

The Reason: The attending physician also must document the reason for the consultation in the patients medical record.

The Report: After the evaluation, the consulting gastroenterologist must issue a written report back to the referring ED physician for the patient evaluation to be considered a consultation. Typically, the gastroenterologist will make a progress note in the patients medical record at the time of the evaluation and then dictate a written report later.

That written report often is quite detailed, says Janet Leineke, CCS, CPC-H, senior outpatient consultant for Laguna Medical Systems, a health information management consulting, outsourcing and education services company headquartered in San Clemente, CA. Because neither the emergency room physician nor the consulting gastroenterologist knows much about the patient, she believes that the consultation will be very thorough to find out as much about the patient as possible.

Determining Transfer of Care Is Tricky

Deciding whether the gastroenterologist took over the patients care may be more difficult to determine in this setting. The most recent Medicare instructions on consultations (Transmittal No. 1644, August 1999) provide that payment may be made regardless of treatment initiation unless a transfer of care occurs. Because the requesting physician in this situation is not the patients regular primary care physician, its difficult to decide at what point he or she is assigning the responsibility for the patients complete care to the receiving gastroenterologist, which is the Medicare standard for determining whether a transfer has occurred.

Gastroenterologists are more likely to experience a transfer of care from emergency room physicians than be asked to perform consultation services, notes Scichilone.
Medicare pays the higher level of reimbursement for a consultation because of the added value of the work involved, such as the extra effort to write a report and the level of decision making involved, she explains.
Gastroenterologists can bill for a consultation with confidence if they meet the three Rs previously outlined, Scichilone adds. Medicares going to be looking for those three conditions to be met, along with documentation that supports the medical necessity of a consultation service.

Code as an Office Consultation

Gastroenterologists should bill emergency room consultations using codes 99241-99245 (office or other outpatient consultation, new or established patient). The CPT manual specifically states that these codes should be used to report consultations done in a physicians office or in an outpatient or ambulatory facility such as an emergency department. If the gastroenterologist decides that the evaluation is not a consult and the patient is discharged from the emergency department or admitted to the hospital by another physician, then it should be billed as an emergency department visit using codes 99281-99285 (emergency department services, new or established patient). If the consulting gastroenterologist admits the patient to the hospital and the criteria for a consultation are not met, then he or she should bill it as initial hospital care (99221-99223).

Another example of when a gastroenterologist may use the codes for an emergency department visit (99281-99285) is when he or she is the primary physician in an emergency room setting. In some rural communities, Scichilone notes, there is no emergency room physician per se. If the hospitals emergency personnel determine that a patient needs a gastroenterologist, then one is called to the hospital. In that case, the gastroenterologist then becomes the patients primary emergency department physician and should use the emergency department visit codes. The reimbursement received for this emergency room visit will be less than for a consultation of the same level.

Modifier -25 May Get
Medicare Reimbursement

After a consultation, a gastroenterologist frequently may recommend that a procedure such as a colonoscopy be done immediately. It may be difficult, however, to get reimbursed for the procedure and the consultation performed on the same day, cautions Scicholone. Thats because many health plans consider the evaluation and management (E/M) consultation to be included in the allowance for the procedure.

Medicare will pay for the consultation that leads to a decision for surgery, she says. But some private insurance companies consider that decision to be a pre-operative service that is included in the surgical fee.
Medicares national guidelines require appending modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M consultation code for procedures with zero to 10 days in the global period, Scichilone points out. Documentation in the claim also must support the E/M service as being significant and separately identifiable, or the service will be considered part of the normal, pre-operative work for the procedure, which is not reimbursed separately.

Under Medicares guidelines, for example, a level-three emergency department consultation done on the same day as a diagnostic colonoscopy, which has no follow-up period, would be coded 99243-25 for the consult and 45378 for the colonoscopy. (A level three consultation also carries with it the key elements of a detailed history, an examination and medical decision making of at least low complexity.)

Some Payers May Require Modifier -57

Although Medicares national standard is to use modifier -25, gastroenterologists may find that some local payers require them to add modifier -57 (decision for surgery) to the consultation code instead. In fact, the CPT states that modifier -25 should not be used to report an E/M service that results in a decision to perform surgery. Instead, the CPT recommends the use of modifier -57, which is how Leineke suggests all emergency room consultations be coded.
In her opinion, modifier -25 should be used when the surgical procedure has been planned in advance and a patient evaluationother than the decision to do surgeryis done on the same day as the procedure.

And although some might question whether a colonoscopy constitutes surgery, Leineke points out that it is listed as such in the CPT.

Because coding and reimbursement for emergency room consultations coupled with same-day procedures are subject to so much variation among Medicare and private insurance companies, gastroenterologists should contact their local payers for their specific policies and coding instructions. In addition, gastroenterologists should get a written copy of any policy that requires them to use modifier -57 on such claims.