General Surgery Coding Alert

Question: Our physician is "on-call" for another surgeon. If he sees one of the surgeon's established patients for the first time, should we report a new or established patient visit?

Michigan Subscriber

Answer: If an on-call surgeon visits a patient for a related problem during a postsurgical global period, you may not charge for any services. To recoup some reimbursement for such visits, you will have to work out a payment arrangement with the physician you are covering for, or trade services on a quid-pro-quo basis.
 
For cases not involving postoperative care, you may be tempted to report a new patient visit. But, CPT specifically states, "In the instance where a physician is on-call for or covering for another, the patient's encounter will be classified as it would have been by the doctor who is not available."
 
In other words, if the patient is not new to the physician your physician is covering for, you must report an established patient visit. For instance, if your surgeon is checking on a patient admitted by another doctor for whom he is on-call, you should report the appropriate subsequent hospital care code (99231-99233).
 
An on-call surgeon can bill for an initial inpatient consultation if:
 1. the patient was referred directly to the on-call surgeon or to the physician the on-call surgeon is covering for; or,
 2. the on-call surgeon is the admitting physician.
 
In either case, the visit would have to meet all the criteria of a consult (request for consultation, review of the patient, and report back to the referring physician).