Reader Question:
ED Visit or Consultation
Published on Fri Mar 01, 2002
Question: Our gastroenterologist saw a patient in the hospital and billed a consultation. The patient was released but came back to the emergency department (ED) the following week. The gastroenterologist has documentation that he did a consultation, but I am wondering if we can bill another consult or if we should code for an ED visit.
Pennsylvania Subscriber
Answer: Billing for visits to the ED is confusing and depends on the specifics of the incident. If the ED physician requested a consultation from your gastroenterologist, you may bill an office or other outpatient consultation (99241-99245) if your gastroenterologist does not perform any other E/M service for the patient that day. The traditional criteria for a consultation (opinion requested, opinion rendered, and opinion reported back to the requesting physician) must be met.
Note: When the gastroenterologist saw the patient in the hospital, you probably billed an initial inpatient consultation (99251-99255), but consults in the ED are considered to be outpatient services, according to CPT.
If the gastroenterologist admits the patient to the hospital on the same calendar day as the ED visit, an initial hospital care code (99221-99223) should be reported instead of an outpatient consultation. All evaluation and management services provided by a physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission, states Medicare Carriers Manual (MCM) section 15507F.1
Sometimes the patient will call the gastroenterologists office and is told to go straight to the ED. If the ED physician calls your gastroenterologist in for a consultation under those circumstances and discharges the patient on the advice of your gastroenterologist, you should report an ED visit code (99281-99285), not a consultation. You cannot bill a consultation because your gastroenterologist is not providing information to the emergency department physician for his or her use in treating the patient, according to MCM section 15507F.2.
Remember that the ED physician will also be reporting an ED visit code for his/her services in this last example, and some insurers may not permit two ED visits on the same date. You should be prepared to provide documentation and appeal the denial if possible.
A final scenario to consider is when the gastroenterologist simply asks the patient to meet him or her at the ED instead of the office. If this occurs, and the patient is not registered as an ED patient, the gastroenterologist should report an office or outpatient visit code (99201-99215).
The gastroenterologists documentation must support the type and level of service provided. For the consultation and ED codes, the level of code reported will be based on all of the three key components (history, examination, medical decision-making). For the outpatient visit codes (99211-99215), [...]
