Gastroenterology Coding Alert

Get the scoop on consult reimbursement.

Last month, Gastroenterology Coding Alert outlined the updated office/outpatient consultation evaluation and management (E/M) codes and guidelines that are set to take effect Jan. 1, 2023. Now it’s time to learn how to correctly choose the level of medical decision making (MDM), what to do when a consultation includes initial diagnostic testing, and whether payers are likely to reimburse.

Before learning about how to apply the codes and what payers will do, however, catch up by reading “Review the Revamped Office/Outpatient Consultation Codes, Part 1” here: www.aapc.com/codes/coding-newsletters/my-gastroenterology-coding-alert/news-you-can-use-review-the-revamped-officeoutpatient-consultations-codes-part-1-173078-article.

Determine the MDM Level for Patients With Multiple Conditions

If a patient visits your gastroenterology practice for a consultation, several factors influence the service level and your code selection. MDM levels will not depend on whether the patient is experiencing multiple new or established conditions at the time of the encounter, but whether those conditions are acute or chronic. “2023 MDM is similar to the 2021 rules in that the new or established conditions do not matter as much as whether those problem were addressed and managed,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Of course, selecting the level of MDM requires more than determining the number and complexity of problems addressed at the encounter. “With the revised MDM calculations, the coder must also consider the amount or complexity of data to be reviewed and analyzed, as well as the risk of complications or morbidity or mortality of patient management. Two of these three areas must meet or exceed the requirements for any given level in order to assign an E/M code,” says Nancy Clark, CPC, COC, CPMA, COPC, CPC-I, AAPC Fellow, senior manager at EisnerAmper Advisory Group in Iselin, New Jersey.

Scenario: A patient visits your gastroenterology practice with an acute exacerbation of their chronic gastroesophageal reflux disease (GERD), as well as prescription management. This patient has come in several times for GERD during the year. During this consultation, the gastroenterologist decides to adjust the patient’s medication after discussing the patient’s condition with the patient’s primary care physician (PCP).

This scenario could qualify as moderate complexity since one chronic illness with exacerbation was addressed, the physician discussed the patient’s management with their PCP, and the provider made an adjustment to the patient’s medication. The provider met moderate complexity in all three areas, even though two areas would have sufficed.

Code Diagnostic Testing During a Consultation

During an outpatient consultation, the provider may decide to perform a diagnostic test to receive up-to-date results prior to determining a treatment plan. According to the AMA consultation guidelines, “A physician or other qualified health care professional consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.”

Take a look at the following tips for knowing if you can report the consultation and diagnostic testing codes together:

• Tip 1: Show medical necessity. Review the provider’s documentation to ensure the diagnostic test and the E/M visit are both medically necessary and documented.
• Tip 2: Check National Correct Coding Initiative (NCCI) and payer edits. Review NCCI and payer-specific edit pairs to confirm whether your selected CPT^® codes are bundled and shouldn’t be separately reported at the same encounter.

Scenario: Your gastroenterologist performs a consultation with a patient for symptoms and/or lab findings that might indicate a diagnosis of celiac disease. The provider then performs an esophagogastroduodenoscopy (EGD) and biopsy on the same day as the E/M visit. Since the patient has only been evaluated by their general practitioner (GP), the gastroenterologist documents the need to establish a definitive diagnosis or exclusion of the patient’s condition prior to advising treatment.

For this visit, you’ll need to report the appropriate consultation code along with the EGD CPT^® code. Depending on what was determined in the consultation and the associated MDM level, you may assign either of the following 2023 E/M codes:

• 99243 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.)
• 99244 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.)

Then assign 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) to report the EGD.

In the scenario, the gastroenterologist documented the need for the EGD during the consultation. Additionally, NCCI doesn’t bundle 43235 with 99243 or 99244 (based on fourth quarter 2022 edits), which means you can report the appropriate codes for the encounter.

Note: If the provider’s documentation supports medical necessity, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code.

Alter Your Coding for Some Payers

While the CPT^® code set includes consultation codes, many providers misunderstand the CPT^® concept of consultations, and the codes are often used inappropriately, such as when a physician or other provider refers a patient to a specialist. “Per CPT^®, the key requirement of a consultation is that a physician or other appropriate source requests an opinion or advice from a physician; and that physician renders the advice and/ or opinion back to the requesting provider,” Clark says. CPT_^® revised the 2023 E/M consultation guidelines to eliminate the “transfer of care” term since the term may have caused confusion as to the appropriate use.

At the end of the day, the real question is if payers will even reimburse for consultations. “Medicare does not recognize consult codes, and will likely still not recognize them,” Pohlig says. This is due, in part, to the misuse and under documentation of consultation codes. In fact, the recently released calendar year (CY) 2023 Medicare Physician Fee Schedule proposed rule indicates the Centers for Medicare & Medicaid Services (CMS) is proposing to “maintain the current billing policies that apply to E/Ms while we consider potential revisions that might be necessary in future rulemaking.” This is in addition to proposing to adopt the other E/M visit coding and documentation changes (www.federalregister.gov/documents/2022/07/29/2022-14562/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other).

If a payer doesn’t recognize consultation codes and a practice submits one, the practice will likely receive a denial indicating the procedure code is not covered. “In this case, the practice has the opportunity to identify the issue, correct the claim, and resubmit the appropriate new or established patient code,” Pohlig says.

“For payers that do not accept consultation codes, the appropriate level of new or established patient E/M service should be utilized,” Clark says.

You’ll report a new (99202-99205) or established patient E/M visit code (99212-99215), depending on if the patient has received face-to-face services from a provider in the practice within the last three years.

Of course, you should review your individual payer policies to see how office/outpatient consultations should be reported to receive proper reimbursement.