Gastroenterology Coding Alert

Patients often are referred to gastroenterologists by other physicians in their practice. This raises questions because gastroenterologists may be confused regarding whether to bill for a consultation or an office visit. But establishing which physician is primarily responsible for the patients care will determine the gastroenterologists reimbursement level.

For example, surgeons discovered the colon cancer that forced Peanuts creator Charles Schulz (who passed away Feb. 12) into retirement during an operation to repair the cartoonists aorta. This situation occurs frequently in an outpatient setting, particularly in multispecialty practices. A patient visits his or her primary-care physician (or other specialist) for a non-gastrointestinal problem, but the patient discloses that he or she has experienced a symptom such a rectal bleeding that indicates a gastrointestinal disorder. If the physician recommends that the patient see the practices gastroenterologist, how should the coding be handled for the gastroenterologists bill?

Whether this is a consultation or new patient visit to the gastroenterologist is the main issue that needs to be determined, according to Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn. A consultation, she explains, must contain the three Rs:

1. Request: The referring physician must request a consult and note that request in the patients medical record.

2. Reason: In this case, the referring physician would cite the rectal bleeding as the reason for the consultation and also document that in the patients record.

3. Report: After the evaluation, the consulting gastroenterologist must issue a written report back to the referring physician detailing the results of the consultation.

Transfer of Care Determines Consult or Office Visit

In most situations when the patient is referred from one physician to a gastroenterologist in the same practice, there wont be any trouble meeting the three Rs, says Stout. They may have difficulty, however, with another aspect of consultationsjudging whether or not a transfer of care took place. In a policy memo dated August 1999, Medicare stated that an evaluation is not a consultation if a complete transfer of care occurs. The memo defines transfers of care as when the referring physician transfers the responsibility for the patients complete care to the receiving physician at the time of the referral.

The phrase at the time of the referral is what is important here, notes Stout. If the referring physician walks down the hall to talk with the gastroenterologist about his or her patient and turns over care of the patient to the gastroenterologist at that point, then the referral is not a consultation but a new patient office visit because no evaluation has taken place. If the evaluation is completed before care of the patient is transferred to the gastroenterologist, then its considered a consultation.

Theres a financial incentive to billing for a consultation because it is reimbursed at a higher level than a new patient office visit, explains Stout. A level three consultation (99243) has a relative value unit (RVU) of 3.19 versus 2.43 RVUs for a level three new patient office visit (99203).

There should be no problem with the practice billing an established patient office visit and either a consultation or new patient office visit to the same patient on the same day, according to Stout, especially because the physicians involved will be using two different diagnoses. No modifiers need to be added to the evaluation and management (E/M) codes.

Two Physicians Check the Same Symptoms

If a patient experiences abdominal pain and visits his or her primary-care physician, who then refers the patient to a gastroenterologist to determine whether the pains are symptoms of any gastrointestinal disorders, the situation has changed because both E/M visits will have the same diagnosis. Although Stout acknowledges that some payers may look twice at these claims, she believes that both should be reimbursed because the patient is seeing two different physicians with different specialties. There should be documentation in the patients medical record from both providers to support the medical necessity of both visits. If one or both visits are denied, I would appeal, she says.

One way to avoid any reimbursement problems is to have the patient come for the second appointment on a different day. This probably occurs naturally in most practices because appointments have to be scheduled a day or two in advance, according to Denine Hallgarth, office manager at Madison Internal Medicine, a 40-physician multispecialty practice in Hanover, Ind., with two gastroenterologists.

The most important thing a gastroenterologist can do in this situation is a thorough job of documentation, concludes Stout, because to the payer that documentation is what will support the medical necessity of the visit. Whether or not the claim is paid on appeal often depends on the value of the gastroenterologists documentation.