Wiki Consultation vs E&M

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drhoads

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I have two cases in question.

Case #1. Pt referred by PCP to specialist for a screening colonoscopy. Pt is asymptomatic but has a family history of colon carcinoma. Specialist scheduled colonoscopy. Physician is billing cpt 99202-99205.

Case#2. Pt referred by PCP to specialist for a screening colonoscopy. Pt is symptomatic, rectal bleeding, abd pain and bloating. Specialist scheduled colonoscopy. Physician is billing cpt 99202-99205.

Case #1. I agree with using E&M, but #2 I feel it should be billed as a consultation cpt 99241-99245. Both are non-Medicare. Would anyone agree?
 
I disagree with the second one being a consult. Consults are about intent, the PCP sent the patient to the specialist with the intent the specialist manage the issue, not for the specialist to tell the PCP how to handle it. Both cases you describe are transfers of care in my opinion.

Laura, CPC, CPMA, CEMC
 
Even though case #2 was symptomatic you still would not bill a consult? I don't know why I always seem to question whether to bill for consult or E&M.
 
LLovett is correct.... case number 2 is not a consult. If the PCP sent the patient to the specialist in order for the specialist to examine the patient, and then render an opinion on the treatment back to the PCP, who would then treat the patient, then that would be a consult. If the specialist is also going to treat the patient, then this is not a consult but a transfer of care for that particular issue. Whether the patient is symptomatic or not has no bearing on the issue.
 
Case #1

If symptoms don't matter (agree), then what would you do with case #1? Bill it as a consult, since right now, we don't know if the specialist will continue with care for the patient or not - it would depend on the results of the colonoscopy. Assuming that if there are findings, the specialist would address it and if there are none, the patient will continue to be treated by the PCP.
 
The decision between a consult and a referral comes down to the intent of the PCP. If the PCP sent the patient to the specialist to be treated for a specific problem, then that is a referral and the specialist would bill from the 99202-99205 codes. If the PCP intends for the specialist to suggest treatment options and send the patient back to the PCP for the actual treatment, that is a consult.
 
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