General Surgery Coding Alert

Reader Question:

Co-Management May Warrant Consult

Question: Can I report a consultation if the surgeon helps to co-manage a patient's care?

South Carolina Subscriber Answer: Depending on the level of co-management, you should be able to report a consultation for your physician's services. For example, if the surgeon performs an initial consultation for an accident victim and then co-manages her rehabilitation with a physical therapist, you can report a consultation for your first visit. Thereafter, however, you should report the subsequent office visit codes (99211-99215) when you evaluate the patient in your office.

Remember that you can only report a consultation code (99241-99245 for outpatients, 99251-99255 for inpatients) if the service meets all of the requirements. This means that you must maintain documentation of the request for your opinion, notes from your patient examination, and a copy of the written report that you sent to the requesting physician. -- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.
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