EM Coding Alert

Question: A surgeon requested that our anesthesiologist evaluate a patient regarding postoperative epidural insertion. The anesthesiologist felt the patient was not a good candidate for the catheter and recommended using oral pain medications instead. Can we report a consult for this encounter?

Massachusetts Subscriber

Answer: Your anesthesiologist saw the patient for a new reason – not the reason for the original procedure/encounter. As long he or she completed a history and physical and made a treatment recommendation, you should be able to report a consult (presuming consultation codes are accepted by the payer and you have sufficient supporting documentation).

The correct code will depend on whether the anesthesiologist performing the consult also oversaw thepatient during the original procedure. If so, report 9923x (Subsequent hospital care, per day, for the evaluation and management of a patient ...). If your anesthesiologist first saw the patient for the consult, report 9925x (Initial inpatient consultation for a new or established patient ...).