Gastroenterology Coding Alert

Reader Question:

Check Rules for Reporting Consultations Prior to Performing a Procedure

Published on Mon Aug 13, 2012

Question: If our gastroenterologist performs a procedure, can we bill for a consultation provided prior to the procedure performed?

New Jersey Subscriber

Answer: You can bill for a consultation provided prior to your gastroenterologist performing a procedure, as long as the following guidelines are met:

Your gastroenterologist is the admitting or the consulting physician and is seeing the patient for the first time (providing an initial evaluation or consultation)
Your gastroenterologist is the one who is making the decision to proceed to perform the procedure.

You will have to append the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or the modifier 57 (Decision for surgery) as appropriate to the consultation code that you will be reporting. Do not make the mistake of appending the modifier to the procedure code as the payer will then consider the consultation codes to be a part of the procedural code and you will not receive a separate payment for the consultation codes.

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