Gastroenterology Coding Alert

Question: How often can we report consult codes for the same patient? We saw a patient in October for a consult, and then the gastroenterologist saw her again for another consultation from a different referring physician in February. Can we bill both consults? Our Blue Cross insurer still allows consultation billing.

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Answer: The outpatient consultation codes (99241-99245) do not have frequency restrictions, and the patient does not need to present with a new problem for you to use an additional consultation code.

According to CPT^®, “If an additional request for an opinion or advice regarding the same or a new problem is received from another physician or appropriate source and documented in the medical record, the office consultation codes may be used again.”

Typically, when a patient returns at the direction of a referral source for an additional consultation, they have a problem that is unrelated to the original complaint or has a progression of the original problem. If the physician performs an additional consultation for a given patient, be sure the documentation includes a detailed explanation for the subsequent consultation(s).

Watch this rule: Medicare policy (Medicare Claims Processing Manual, Chapter 12) states, “if the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services shall not be reported.” So be absolutely sure that you can demonstrate the second consultation request and that your physician documented it.