Gastroenterology Coding Alert

Get Consult Documentation - 1 Way or Another

When you submit a consult claim, include documentation that explains the consultation circumstances. "I recommend that the consultant have the referring office fill out a request-for-consult form and fax it back to your office," Jandroep says.

Even if you don't use consult-request forms, there are ways to note the details of a consult on a claim.

How? One way is having the consulting gastroenterologist include a note on the claim explaining the details of the visit, Green says.

For example, the gastroenterologist billing for the Dr. P consult in the above example could include a note with words to this effect: "I am seeing this patient today at the request of Dr. P for my opinion on the patient's persistent vomiting and abnormal bowel sounds."

"This documentation should either be copied to the requesting physician or be sent in letter form back to the requesting physician. This should provide sufficient evidence that it was a true consultation [because it satisfies] the three R's: Request, Render the Service, and Report Back," Green says.

Still Stumped? Try This Trick

Coders can also help their consult-identifying cause by thinking of consults as a "circle of care." In a consultation, the requesting physician sends the patient to the gastroenterologist, who provides his opinion. At the end of the visit, the patient returns to the requesting physician for care and the circle is complete.
 
But if the gastroenterologist takes over the patient's treatment after the initial encounter, the circle is broken and the visit is likely a referral.

Referrals Draw a Straight Line to Gastro Office

While there is a "circle of care" when your gastroenterologist provides a consultation, it looks more like a "direct line of care" when your gastroenterologist gives referral services.

What makes it a referral? A referral is the transfer of responsibility for a patient's care from one physician to another. After your gastroenterologist provides a referral service, she is usually the patient's primary physician for treatment of the condition, Jandroep says. "Sometimes, however, the referring physician will only refer part of the care to a gastroenterologist, such as when the patient has a GI operation, but there are still some cardiac issues that another specialist would treat," Jandroep says.

Key point: Unlike consultations, referrals do not have their own code sets. You should report referrals using the E/M codes from the new patient code set, Green says.

Example: A patient reports to the office at the request of another physician. After providing a level-four service, the gastroenterologist decides that the patient may have one of several esophageal disorders. The gastroenterologist then schedules the patient for a follow-up visit for more tests and potential treatments.

In this instance, the gastroenterologist took over care of the patient's esophageal problems, so the service is a referral. On the claim, you should report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the referral.

Proving that a visit was a consultation might be a tad more challenging than reporting a referral. To alleviate this problem, Jandroep recommends that you get some proof of the request from the requesting office for referrals as well.

"It is professional courtesy to send a [request form] even for a referral," she says.