Gastroenterology Coding Alert

Before you report any consult service in the range 99241-99255, the physician must document these three basic requirements:

1. A physician or other appropriate source must request the consultation. The performing physician must record the request in his documentation.

2. The consulting physician must document his visit with the patient and render an opinion regarding the patient's condition.

3. The consulting physician must prepare a written report of his findings, which he must provide to the requesting/referring physician (this can be recorded in the shared patient record for inpatient consultations).

Remember: A consulting physician may initiate treatment and/or provide diagnostic testing and still report a consult. If the physician accepts primary responsibility for the patient, however, a transfer of care has occurred, and you should report a new or established patient visit, depending on the situation and setting.