Reimbursement for Both ER Consultations and Same-day Procedures
Published on Mon Nov 01, 1999
After a consultation, gastroenterologists frequently may recommend immediately doing a procedure such as a colonoscopy. But they may have difficulty getting reimbursed for both the consultation and the procedure performed on the same day. Coding properly and adhering to the patients health plan guidelines should alleviate reimbursement headaches.
A gastroenterologist gets called to the emergency room to do a consultation on a patient with rectal bleeding. Once he or she evaluates the patient, the physician decides to do a procedure like a colonoscopy, says Angie Burns, who manages the billing department for Dr. Richard Kuritzkes practice in Burbank, CA. The problem is that usually theres no reimbursement for the
consultation, even though its not part of the procedure.
But this isnt always the case. Although some local Medicare offices and private insurance companies have stated that they will not reimburse for both a consultation and a procedure that are performed on the same day, others will payprovided the health plan coverage conditions are met, and the coding is reported correctly.
Documentation Is the Key
First, coders must determine whether the gastroenterologist performed a consultation (99241-99245) or a visit with a new patient (99201-99215). Even though the evaluation took place in an emergency room, the three basic criteria for a consultation still apply, according to Rita Scichilone, MHSA, RRA, CCS, CCS-P, medical coding practice manager for the American Health Information Management Association, a Chicago-based organization representing more than 38,000 health information management professionals.
The emergency room is no different than any other outpatient setting, she says. A consultation still has
to have the three Rs: a request from an appropriate source, a reason for the consultation, and a written report from the consulting gastroenterologist back to the requesting physician.
The Request: In this case, the requesting physician is an emergency room doctor whose request for a consultation must be recorded in the patients medical record. Recent Medicare guidelines state that a simple entry in the emergency departments common medical record for the patient is adequate.
The Reason: The attending physician also must document the reason for the consultation in the patients medical record.
The Report: After the evaluation, the consulting gastroenterologist must issue a written report back to the referring ED physician for the patient evaluation to be considered a consultation. Typically, the gastroenterologist will make a progress note in the patients medical record at the time of the evaluation and then dictate a written report later.
That written report often is quite detailed, says Janet Leineke, CCS, CPC-H, senior [...]
