Consult Uh OH

KimmHall

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Hello my fellow Coders,
I am posting this underneath two forums because it applies to both and I need as much feedback as I can get.
Yesterday I was thrown for a bit of a loop during a Medicare Webinar on consults that seemed to change what I have always been accustomed to. I am not new to coding however consults have been under quite a bit if scrutiny and I am trying to be as educated as possible so that I can educate my doctors as well.
Here is my scenario and question:
A patient presents to the ER with dysphagia. The ER doctor requests a GI consult. GI comes in and examines the patient (performs all the components of an E/M level). GI subsequently takes the patient to the endoscopy unit (or stays in the ER) and performs and EGD and removes a fish bone. The patient is discharged home with follow up instructions.

Question: Does GI bill a consult code? Why or why not?

PS: I know that a modifier would be needed on the E/M, and the procedural and dx coding my main focus is whether or not this is a true consult.

Thank You in advance for sharing your thoughts and opinions with me.

Kimm Hall CPC, CGCS, CMSCS
 

LLovett

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I don't see this as a consult. The ED physician called the GI in for the purpose of taking over care, not to help him treat the problem.

It is almost impossible, based on my understanding of consults, to get a consult from an ED physician. The intent of a consult is to get advice or opinion on how to manage/treat a problem, then the patient goes back to the originating provider for continued care. ED physicians don't manage problems, they treat what they can and send the rest on to other providers.

Just my opinion,

Laura, CPC
 

Lisa Bledsoe

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I am in total agreement with Laura. Specialists seem to be under the impression that all patients they see at the request of another provider is a consult. But that is not always the case. As Laura said, if the requesting provider just wants an opinion/advice on how to treat the problem, then it's a consult (the consulting provider can initiate treatment, but the patient must go back to the original provider for continued care). If the requesting provider intends for the "consulting" provider to treat the problem, it's a new patient. Hard to get that across to some providers...
 

RebeccaWoodward*

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I do see your point, but in my opinion, it's not impossible. CPT indicates that CPT codes 99241-99245 are also used in the emergency department.
 

RebeccaWoodward*

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While this particular scenario may seem a little muddy as far as the intent, someone I greatly admire shared this with me.

There are still many cases where the ED physician is asking for an opinion, usually regarding whether the patient's presenting problem is related to a certain body system that pertains to a certain specialty. For example, chest pain can be caused by several things—respiratory distress, coronary pathology, hiatal hernia, etc., each of which is handled by a physician of a different specialty. The ED provider may not feel comfortable making the final dx, and so will make their best guess as to which one is the likeliest candidate and usually call that specialty in first to provide an opinion. Let's say the ED provider calls in Cardiology to provide an opinion as to whether or not the problem is a cardiological one. The ED provider does not KNOW that the Cardiology provider coming to the ED as a result of their request will be taking over because they don't even know yet if the patient's problem is cardiological in nature—that's the whole point of asking for the cardiological opinion/consult. Let's say in this situation that the cardiologist consultant provides the opinion that the patient's problem is NOT in fact related to any coronary pathology that they can find. At this point, the ED provider may choose to discharge the patient, order add'l tests, or consult another specialty.

So because of the fact that ED providers often request opinions from specialists in order to rule out certain conditions and to help them determine who they should call or consult next, the services they request will often be accurately billed by the requested provider as a consult.
 

Karolina

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For the scenario in question here, I agree with Laura that it is not likely a consult. Based on the limited information available it seems to me that the ED physician called GI to deal with the issue - no opinion for further management requested.
Generally, I find the outline rebecca posted very helpful as it details the circumstances under which a consult from the ED doc would be appropriate.
Is there more documentation that would be in line with any of that?
 

KimmHall

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Thank you all so much for your input andhonestly I can see both sides a lot more clearly. Basically it will be extremely dependent onthe situation. While we do not often see ER patients just the mere thought of doing it wrong was really bugging me. Thankas again so much for taking your time to offer your opinions. I am not here as often as I would like to be but I do value the opions of my peers very highly.
 
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