Gastroenterology Coding Alert

Question: My gastroenterologist recently saw a patient at the request of the primary-care physician. The patient complained of severe fatigue and rapid weight loss and showed signs of jaundice. After performing a comprehensive history and exam with moderate medical decision making, the physician diagnosed acute hepatitis C without hepatic coma. My gastroenterologist recorded his findings and provided a report to the requesting physician. How should I report this visit?Florida SubscriberAnswer: You should report 99244 (Office consultation for a new or established patient ... requires these three components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity) for the initial consultation.Keep in mind: Be sure you have met all the documentation requirements for a consult visit before billing it as such. Documentation requirements for consultations vary by payer, but experts say your consultation documentation should at least include evidence of the following "R's":• The name of the [...]