Gastroenterology Coding Alert

Your physician can provide treatment and still claim a consult

When your gastroenterologist accepts responsibility for managing even a portion of a patient's care, you can no longer report a consult code for that patient. Just because your doctor provides some care, however, doesn't mean a transfer of care has occurred.

Here are four tips to help you distinguish between consults and transfer of care. 1. Don't Let Language Fool You Even if another physician -refers- a patient to your gastroenterologist, you shouldn't assume the visit is a referral or transfer of care. Choosing a standard E/M service code instead of a consult (when the consult is appropriate) will cut into your practice's bottom line because standard E/M visits generally pay less than consults.

-Doctors may tell a patient, -I-m going to refer you to a specialist to see exactly what your problem is.- But they aren't always clear what they mean by -refer.- This can spell trouble for coders trying to choose a correct E/M service code,- says Marvel Hammer, RN, CPC, CHCO, a consultant with MJH Consulting in Denver.

Let the Three R's guide you: Likewise, if the gastroenterologist says he -consulted- with the patient, you shouldn't automatically choose a consult code. CPT defines a -consult- as a very specific service that involves three components:

- a request from another physician for a consult
- an opinion rendered by the consulting physician
- a report on the patient's condition sent by the consulting physician to the requesting doctor. If the service your GI provides doesn't meet all of these three conditions, you cannot report a consult. 2. Document the Request If a patient visits your gastroenterologist on his own accord, you must select a standard E/M code to report the service (for example, 99201-99205 for new patients or 99211-99215 for established patients).

-The patient may have a recommendation from the attending doctor to see a physician in a particular specialty group,- says Cindy Parman, CPC, CPC-H, RCC, principal of Coding Strategies Inc. in Powder Springs, Ga., but you cannot bill for a consult if -the -consulting- physician does not note the consult request in the patient documentation.- Even a note stating, for instance, -Dr. Gastro is seeing Mrs. Smith on the recommendation of her primary-care physician, Dr. Jones, because of _____,- can suffice for the request from another healthcare provider.

Bottom line: The attending physician's request (to support the consultation service) must be available as a part of the patient's medical record either mentioned within the visit note or as a separate written note from the requesting healthcare provider. 3. Consult Can Include Care You may report a consult even if your gastro-enterologist schedules testing or initiates care for the patient--as long as the visit meets the [...]