General Surgery Coding Alert

Experts advise you on choosing a consult category

After you've documented a request, reason and response, how should you choose a correct consultation category? The answer is in the documentation, say coding experts. Follow these examples when selecting the appropriate code from one of three consult categories:

Office or other outpatient (99241-99245): These codes describe consultations provided in the physician's office or in an outpatient or other ambulatory facility.
 
For example, a patient with inflammatory bowel disease presents to his primary-care physician (PCP) with pain in the lower right quadrant, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. The PCP documents these symptoms and requests a consult from the surgeon. The surgeon examines the patient and determines that the patient needs further testing (for instance, imaging studies). After testing, the surgeon confirms a diagnosis of intra-abdominal abscess and prepares a report to the requesting physician.
 
In this case, you would report the appropriate outpatient consultation code (9924x) along with the code(s) for imaging studies or other diagnostic tests, Sandham says. Bill any subsequent visits for treatment with the appropriate office outpatient codes (9921x).

Initial inpatient (99251-99255): Use these codes to report consultations provided for hospital inpatients and those in partial hospital settings or nursing facilities, CPT states. Remember that the same physician may report only one inpatient consult per inpatient stay, says Dianna Hofbeck, RN, CCM, ACFE, president of North Shore Medicine Inc., a national billing service in southern N.J. For additional consults the surgeon provides during the same inpatient stay, report the follow-up inpatient codes (discussed below). If the physician discharges the patient and readmits him or her later, you may report another initial inpatient consult by the same physician (if it is properly requested and documented), Sandham says.
 
For example, a neurosurgeon requests a consult from a general surgeon for a patient recovering from cranial surgery and complaining of abdominal pain. The general surgeon reports this consult using the appropriate-level initial inpatient code (99251-99255).
 
Three weeks later, the same patient readmits to the hospital for a different problem. During this visit, the same general surgeon again receives a consult request from the patient's attending physician (either for abdominal pain or for a different problem). Because this is a separate inpatient stay, the surgeon should once again claim 99251-99255, as long as he documents the service.

Follow-up inpatient (99261-99263): Report follow-up inpatient consultation codes when the initial consult is complete or when the attending physician requests a subsequent consult during the same inpatient stay, CPT says. For example, the surgeon receives a request to examine in the hospital a patient complaining of stomach pain and fever following a lower endoscopy. In this case, you should code the appropriate initial inpatient consultation code (9925x) along with any diagnostic tests performed (for instance, a flat and upright film to check for free air to rule out perforation as the cause, and a complete blood count), Hofbeck says.
 
The surgeon does not assume responsibility for treating the patient, but several days later receives a second consult request for the same patient during the same stay (either for the same or for a different problem). To report this visit, use the follow-up consult code (9926x) best supported by the surgeon's documentation. (If the surgeon had assumed responsibility for treatment of the patient's condition after the initial consult, you would report his or her follow-up visits using the appropriate subsequent hospital care code[s], 99231-99233.)
 
If the same patient is then discharged and readmitted at a later date, and the surgeon once again treats the patient for stomach pain or a different problem, you may report an initial inpatient consult code, Sandham says.