# Intraoperative consult code ?



## MEZIESKY

Could someone please let me know how to bill for an intra-operative consult. We have run across 2 different cases.  1. would be if  our Dr was call in during surgery for a consult on something and no surgery was performed by our Dr. 2. would be when like the one I have now where our Dr was called in by the operating Dr. for a consult and our Dr. removed the spleen and did a colectomy. Our Dr. wants to get paid for the consult as well as the surgery.
Thank you for any advise
Marie


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## FTessaBartels

*Consult code*

Scenario 1:  Intraoperative consult where consulting physician does NOT perform any surgery.  Bill the appropriate consult code, according to documentation. (Could be inpatient or outpatient depending on patient's hospital admit status vs day surgery). Read my NOTE at the end of this post.

Scenario 2:  *IF* your physician was called to consult and *made a decision for surgery*, which he then performed, then yes, you could code the consult (with a -57 modifier) and the surgery. Read my NOTE at the end of this post
*BUT *... 
IF your physician was called in because the case was too complex for one surgeon to handle, then there is no consult. 

*NOTE:* In my experience, it would be a rare day, indeed, to see documentation that actually supported an intraoperative consult. I rarely see any history documented and physical exam is necessarily very limited by the necessity to maintain a sterile operative field, and the patient's anesthetized condition.  Not saying it never happens ... it's just very rare.  In that case you have a *99499 Unlisted E/M.*

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## lisigirl

I usually have trouble billing for these as well but I think the op note below is a good example of one that could be billed based on time.  My physician did not do the closure he recommended so I billed only the consult code. If had scrubbed in and performed a procedure, I probably would only bill the for the procedure (but I'm not sure if that's correct or not).

DESCRIPTION OF CONSULT:  I was consulted intraoperatively on a 68-year-old
woman who was undergoing repair of a large para-esophageal hernia via
laparoscopic approach. At the time of operation, a Morgagni hernia was
identified and I was asked to consult intraoperatively regarding management
options for this. At the time of arrival, the laparoscopic Nissen
fundoplication had been completed and an examination of the Morgagni was
undertaken. The transverse colon had been herniated in this but was removed
by the time of my arrival. There was no imaging immediately available for
review. The hernia appeared to be a classic Morgagni hernia that extended
for approximately 6 cm transversely. With decreasing the insufflation
pressure and manipulation with the instruments, it appeared that the
diaphragmatic rim of the hernia would reach the anterior costal margin
without substantial tension. I, therefore, recommended a primary closure
with nonabsorbable suture at this juncture. The rim of the hernia sac was
incised. During suture placement, there was a breach of the parietal
pleural layer and a pneumothorax developed which was drained
laparoscopically by incising the pleura further to allow egress of air at
the end of the case. After a suture was placed and it did appear that the
hernia would be adequately closed, I did not recommend a drain placement at
this point outside of suctioning out the chest. I spent 30 minutes
coordinating the intraoperative care and decision making for this patient

Lisi, CPC


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## FTessaBartels

*I think you're right*

Lisi,
This is truly a great note (unlike most of the ones I've seen).  I think you definitely could code 99253 based on time spent (or 99243 if this was an outpatient surgery). 

I will say, though, that from the dictation I can't tell that your surgeon didn't actually perform the closure himself. But if you know for a fact that he didn't do the procedure but was primarily advising and offering his professional opinion/advice, then definitely go for the consult. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## rjconnell

To bill based on time is generally because conseling and/or coordiantion of care is more than 50% of the visit.  Definitely not counseling the patient (who is under) can this be considered co-ordination of care?


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## FTessaBartels

*Coordination of care*



rcashley said:


> To bill based on time is generally because conseling and/or coordiantion of care is more than 50% of the visit.  Definitely not counseling the patient (who is under) can this be considered co-ordination of care?



Yes, definitely, it is coordination of care.  The same rules apply.

F Tessa Bartels, CPC, CEMC


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