Gastroenterology Coding Alert

Turn to 99231-99233 and 99311-99313 for same-stay follow-ups

The AMA will streamline consultation coding for 2006. As a result, you-ll soon report all your physicians- inpatient follow-up visits (now 99261-99263) as subsequent hospital.

Subsequent Care Becomes the Only Choice

Starting Jan. 1, 2006, you should report all facility visits, except the first, during the same inpatient stay using either subsequent care codes 99231-99233 (hospital) or 99311-99313 (nursing facility), depending on the site of service.

Under present guidelines, the gastroenterologist may report a follow-up inpatient consultation for subsequent visits during a single inpatient stay, as long as the visit meets the minimum criteria to report a consult service, says Suzan Hvizdash, BSJ, CPC, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. But without 99261-99263 in 2006, you-ll no longer have that option--even if the service meets the requirements of a consult and the gastroenterologist does not assume responsibility for any portion of the patient's care.

Learn more: See -Billing Consults? Here Are the Requirements- later in this issue, for complete information on the minimum criteria necessary to establish a consult service.

Initial Consults Still Count

You should still report an initial inpatient consult (99251-99255) for the physican's first consultation with the patient per inpatient stay, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Get all the facts: For advice on reporting inpatient consults, see -Easy Inpatient Consult Coding in Just 3 Steps- later in this issue.

Example: The managing physician requests that your gastroenterologist provide a consultation for a hospital inpatient complaining of rectal bleeding (569.3, Hemorrhage of rectum and anus). The gastroenterologist documents the request, examines the patient and shares his findings with the managing physician.

In this case, you should report an initial inpatient consult code (such as 99254, Initial inpatient consultation for a new or established patient ...), as well as any diagnostic tests the gastroenterologist provides (for example, 45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).
 
Don't forget: You must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consult code if the gastroenterologist provides a same-day procedure (such as the sigmoidoscopy).

The next day (suppose it is Jan. 3, 2006), the managing physician once again asks the gastroenterologist to examine the patient because of new symptoms. Once again, the gastroenterologist documents the managing physician's request, examines the patient and shares his findings. 

For the follow-up visit, you should claim subsequent hospital care (for instance, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...). Although this visit looks like a consult, you must report subsequent care because 99261-99263 will not be valid for 2006.

Embrace the Change

Good news: No more 99261-99263 means easier documentation requirements for physicians and fewer headaches for coders trying to choose between follow-up consults and subsequent hospital care, Hvizdash says. You can simply choose 99231-99233 for hospital inpatients or 99311-99313 for nursing facility patients.

Even better news: As a bonus, subsequent hospital care codes generally reimburse better than have follow-up inpatient consultations. -Level for level, subsequent care codes pay at a higher rate than follow-up consultation codes,- Callaway says.

Say -Goodbye- to 99271-99275, Also

For 2006, you-ll also have to make due without 99271-99275 (Confirmatory consultation for a new or established patient ...). That means you-ll have to report either a standard outpatient E/M service (99201-99215) or consult (99241-99245)--depending on the circumstances--for so-called -second (or third) opinions.-

-With no codes for confirmatory consults in 2006, you-ll treat these services like any other E/M service,- Hvizdash says. -If the physician receives a request from an appropriate source to examine the patient, renders an opinion and provides a response, you have an outpatient consult. If the visit does not met those requirements [such as when a patient -self-refers-], you-ll report a standard office visit.-

Example: A patient recently diagnosed with intestinal cancer (for instance, 153.x, Malignant neoplasm of colon) seeks a second opinion before undergoing surgery to remove the affected tissue. Your gastroenterologist provides a full workup and discusses possible outcomes with the patient.

In this case, you should report an appropriate-level new patient visit (such as 99204, Office or other outpatient visit for the evaluation and management of a new patient ...).

An ABN Is a Good Idea for Second Opinions

Whenever possible, you should obtain an advance beneficiary notice if you know that the patient is seeking a second opinion or confirmation of a diagnosis or treatment plan. The ABN lets the patient know that he may be responsible for payment if the insurer considers the service to be unnecessary.

Here's why: In the past, many payers (including Medicare) have not covered confirmatory consults because the insurers considered such -repeat- opinions (especially when generated by the patient and/or family) a -duplication of services,- and therefore medically unnecessary.

This problem may continue to haunt physicians who provide confirmatory opinions for patients. Because another physician has already examined the patient and provided an opinion, the payer may deem any attempt to re-examine the patient a duplication of services--even if you bill the service as an office visit or inpatient or outpatient consultation.