Gastroenterology Coding Alert

Because consultations reimburse more than referrals, they're a tempting coding option to gastroenterologists, but remember to follow 10 guidelines to avoid raising a red flag. Assess Whether Care Was Transferred "A consult is a service rendered to give an opinion to a requesting physician about a patient's condition," says Kristine D. Eckis, CMM, CPC, president of The Bottom Line Medical Administrative Consultants Inc. in Lake Wales, Fla. "A referral is the transfer of responsibility for a patient's care from one physician to another.

"The gastroenterologist can initiate treatment during a consultation," she says. "For example, the patient may need medication, and the gastroenterologist writes a prescription. But the patient eventually returns to the physician who initially requested the consult. The gastroenterologist does not assume care." Determine Intent for Visit Consultations are distinguished by the intent of the visit, adds Jennifer Swindle, RHIT, CCS-P, CPC, coding reimbursement services supervisor for a multi-specialty, 150-physician clinic in Lafayette, Ind. "Typically the physician who requests the consult knows the patient has a problem outside of his or her areas of expertise," she says. "The physician knows that specialized care is needed and sends the patient to be evaluated for treatment." Look for Circle of Care Swindle finds it helpful to think of consults as a "circle" of care. The requesting physician sends the patient to the specialist, the specialist provides treatment and, at the conclusion of the consultation, sends the patient back to the requesting physician. The specialist also sends to the requesting physician a written report of his or her findings and the treatment rendered. If the gastroen-terologist is taking over the patient's care, however, the circle is broken.

Know the Consultation and Referral Codes For consultations in the office or other outpatient setting, use 99241-99245 (Office consultation for a new or established patient). Report inpatient consultations 99251-99255 (Initial inpatient consultation for a new or established patient). For referrals, use a new patient office visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient,), Eckis says. The gastroenterologist assumes care for the patient's problem, which often involves subsequent visits, surgical procedures, ongoing treatment or follow-up care. Consider the Gastroenterologist's Role It is rare for her physicians to be asked to take over complete care of a patient, says Lois Curtis, billing manager for a seven-physician gastroenterologist practice in Indiana. Thus referrals are uncommon in her experience. On the other hand, consults are common.

"Frequently a primary-care physician suspects a problem, such as colitis, and sends the patient to us to diagnose and treat that specific problem," Curtis says. "That physician expects, and we provide, a complete report of our findings and treatment."

Curtis explains that primary-care physicians sometimes [...]