General Surgery Coding Alert

Question: One of our surgeons was called into a surgery-in-progress to consult on a possible rectal injury. How can I capture this "consultation" service?

Texas Subscriber

Answer: The answer depends on the documentation. If the intraoperative consultation is written like a consultation note, then you should choose the appropriate consultation code based on the level of work, such as 99251 (Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making ...).

If the physician documents that the patient was already asleep when he entered the room, gives nominal history based on the record or on the other surgeon's comments and then documents his examination of the area(s) in question along with his/her conclusions, a consultation code is most appropriate.

Proviso: If the payer doesn't accept consultation codes (like Medicare), then an inpatient or outpatient E/M code is appropriate, based on the documented history/exam/medical decision making (HEM).

Problem: Intraoperative consultation reports are often written like an op report, which can make it difficult to code an E/M service. If the surgeon doesn't provide HEM data and didn't perform a procedure, then you'll need to ask him to amend the record to cover the information needed to bill an E/M. Your only other option would be to bill 49000-52 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure], Reduced services), which is almost certainly going to be bundled into any other procedure performed that day.