General Surgery Coding Alert

Question: We commonly see patients referred by another physician for conditions such as infected gallbladder, or breast or colon cancer. Our surgeon performs an office exam that frequently results in a later surgery. Should we code these as consultations or transfer of care? Do we need a written notice from the referring physician for consultations?Texas SubscriberAnswer: Typically, the situations you describe involve a consultation, such as 99241 (Office consultation ...), not a transfer of care.You do not need to have anything in writing from the requesting physician to bill a consult. That said, you should abide by some protocols to ensure you're billing these cases correctly.Document consult: Although you don't need a written request, you do need to document a consultation service. The documentation can come from the referring physician or the consultant. On your end, you can justify the referral by specifically stating in your note who referred the [...]