You Be the Coder:
Untangle PCP Referral Challenges
Published on Wed Jan 01, 2003
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question:
A patient's primary-care physician referred him to one of our cardiologists for shortness of breath following an operation for a coronary artery bypass graft. The cardiologist took over care of the patient during the postoperative period, and the patient had no further contact with the primary-care physician. The cardiologist determined at the visit that the patient has coronary artery disease. How this should be coded?
California Subscriber
Answer: To properly code this situation, you should understand what communication took place between the primary-care physician (PCP) and your cardiologist.
If the PCP requested your cardiologist to consult (requested an opinion or advice) and your cardiologist performed a history and physical and communicated by written report to the requesting physician the consultant's opinion and any services ordered or performed, the service meets the definition of a consultation, so you should use the applicable consultation code level. A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. Your cardiologist diagnosed the patient with hypertensive heart disease (402.x) during the encounter, and you would use that diagnosis on the claim form.
Other considerations include if the PCP's communication meant only to refer the patient to your cardiologist to see and the PCP did not request his or her opinion or advice, then you should consider the service a new patient office visit and base your code selection on the level of E/M care provided.
You do not state how the surgeon who performed the coronary bypass graft billed for his or her care, specific to postoperative care. When practitioners split the postoperative care, you should use modifiers -54 ( Surgical care only) and -55 (Postoperative management only) with the applicable CPT code(s), depending on which practitioner performed which component of care.
These particular situations can be challenging. You should gather all the particular details regarding what has been communicated among the practitioners, which practitioners are handling which portion of the care, and if the care is part of the postoperative surgery care so you can select the most appropriate code for billing. And, medical record documentation must support all services billed. | |
