General Surgery Coding Alert

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 in the patients medical record.
3. After the consultation, the consulting surgeon prepares
a written report of findings that is provided to the requesting physician.

To get paid for the consult, the surgeon must meet these criteria and ensure that:

The request for an opinion is in writing. A verbal request from another physician to see a patient does not qualify.
An actual, separately identifiable consultation report has to be dictated.

If the requesting surgeon does not ask for the surgeons opinion, a consultation may not be claimed. For example, if an OB/GYN inadvertently perforates a patients bowel during a procedure and calls in a general surgeon to repair it, no consultation should be charged, because there was no need for an opinion. Rather, the OB/GYN knew what needed to be done and simply required the general surgeon to actually perform the procedure.

When to Use Standby Codes

Some coders use standby code 99360 (physician standby service, requiring prolonged physician attendance, each 30 minutes [e.g., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG]) to report intraoperative consults. According to CPT, 99360 is used to report physician standby service that is requested by another physician and that involves prolonged physician attendance without direct (face-to-face) contact. The physician may not be providing care or services to other patients during this period.

In addition, CPT states, 99360 should not be used if the period of standby ends with the performance of a procedure subject to a surgical package by the physician who was on standby. If the surgeon who was called in to perform an intraoperative consult does not provide adequate documentation or fails to meet the criteria for a consult, the coder may be tempted to use a standby code. However, there is absolutely no advantage to be had at this time billing for standby services, Johnson says.

Very few carriers will cover a standby as it implies the physician who is standing by has abandoned all of his or her other projects and is waiting and ready to work on the patient. That rarely occurs these days, she says.

In the case of an intraoperative consult, the surgeon is not standing by, he or she is actively assessing the patient and then providing the requesting physician with an opinion. If a decision for surgery is made, the surgeon will perform a procedure as well. If the physician actually performed a consult and did not document it correctly, however, it is unlikely that a claim for standby service could be justified to the rare carrier still willing to pay for such services.