Gastroenterology Coding Alert

You must have the 3 R's to report a consult

If you think you understand the difference between a  consultation and a transfer of care, take this quick quiz to test your knowledge.

Scenario 1: The patient sees his primary-care physician (PCP) to complain about sharp pain in his lower abdomen (789.0x). The PCP recommends that the patient see a gastroenterologist as soon as possible. Three days later, the patient sees the gastroenterologist, who examines the patient and recommends treatment.

Consult, or transfer of care/referral?

Solution 1: In this case, you cannot claim a consult because the visit does not meet the minimum requirements of request, render and report.

The PCP recommended that the patient see the gastroenterologist, but the gastroenterologist did not report his findings back to the PCP.

You should report an appropriate-level new patient office visit (for example, 99204, Office or other outpatient visit for the evaluation and management of a new patient...), as supported by the gastroenterologist's documentation.

Scenario 2: The patient's PCP requests that the gastroenterologist see a patient with a complaint of rectal bleeding (569.3, Hemorrhage of rectum and anus).

The GI examines the patient for 40 minutes, taking the patient's history, performing an exam and deciding to perform a sigmoidoscopy--which does not reveal a more serious problem. The GI discusses his findings with the patient, notes them in the medical record and prepares a report for the PCP outlining those findings.

Consult, or transfer of care/referral?

Solution 2: In this case, you should report an office consultation, such as 99243 (Office consultation for a new or established patient ...). Although the gastroenterologist performed diagnostic sigmoidoscopy, the visit meets all the requirements of a consultation.

Be sure also to report the sigmoidoscopy (for example, 45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and append 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 consult code.

Scenario 3: A woman meets with her PCP and asks about pain in her midsection. The PCP contacts a gastroenterologist colleague and requests that the GI -consult and treat- the patient. The gastroenterologist meets with the patient and, after examination, recommends an endoscopic retrograde cholangiopancreatography (ERCP) at the earliest possible date. The gastroenterologist later performs ERCP, removes calculi from the common bile duct, and performs all follow-up for this procedure.

Consult, or transfer of care/referral?

Solution 3: In this case, the initial visit could be either a consult or a transfer of care, depending on documentation.

Although the PCP requested that the gastroenterologist -consult with and treat- the patient, you may only consider the first visit a consult if the gastroenterologist records the request and reports his findings back to the PCP.

If the gastroenterologist immediately accepts care of the patient, you should report a new outpatient visit (such as 99204) rather than a consult, according to CPT guidelines.

You may report the later ERCP using 43264 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts), as well as any other separately reportable procedures as indicated by the ERCP report.