Get a Request for Consults to Properly Gain Reimbursement
Published on Tue Aug 01, 2000
General surgeons called in to the operating room (OR) to render an opinion should bill intraoperative consultations using inpatient or outpatient consult codes. To do this effectively, however, all the requirements of a consult must be met, coding specialists say. That means the request for the consultation must be documented, in addition to the visit itself, and the surgeon must submit a written report once the consultation is completed.
In an intraoperative consult, the surgeon comes in and examines the patient, offers an opinion, and either takes over for that particular portion of the surgery or leaves the room, says Barbara Johnson, CPC, MPC, a practicing coder in Loma Linda, Calif., member of the National Advisory Board of the American Academy of Professional Coders, and the AAPCs 1999 Coder of the Year. Under these circumstances, what youll have 90 percent of the time is a limited, low-level consultation.
Note: Typically, intraoperative consultations are coded at lower levels because the surgeons ability to perform an examination is severely restricted by the fact that the patient is anesthetized. Whereas the examination portion is lessened due to these circumstances, the opposite applies to taking the patients history. As long as the surgeon documents that he or she was unable to take a history because the patient was anesthetized, the equivalent of a comprehensive (high-level) history can be claimed. The decision-making component of the consult also is at a high level because the patient is in the OR. The weakness of the examination portion usually determines that only a lower-level consult should be billed.
For example, an obstetrician/gynecologist (OB/GYN) is operating on a patient and notices something unusual about the patients appendix. The general surgeon is called in for an opinion and determines that the appendix appears abnormal and should be removed. The general surgeon removes the appendix and then leaves the OR.
In this situation, the general surgeon would bill both for an appropriate level initial inpatient consultation
(9925x) and for the appendectomy (44950). Modifier -57 (decision for surgery) would have to accompany the consultation E/M code; otherwise, it would be bundled with the appendectomy, Johnson says.
If the surgeon determined that the appendix did not require removal, the appropriate level inpatient consultation code should be billed (without modifier -57, as no surgery was performed), but only if the visit has been carefully documented, Johnson says.
The criteria for a consult are described as follows in the Medicare Carriers Manual, section 15506:
1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by a physician.
2. A request for a consultation from the physician and the
need for consultation must be documented [...]
