General Surgery Coding Alert

Question: A new patient came to see a surgeon in our practice to discuss whether she should have a colonoscopy. She said that she thought she might need the procedure because she was worried about bowel habit changes, which she had told her primary physician about. Should we bill the visit as a consultation?

Colorado Subscriber

Answer: No, you should not consider the encounter a consultation because the primary physician did not ask your surgeon for an opinion, and your surgeon is not obligated to send results to the primary physician.

By definition, according to CPT®, a consult is “a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”

That means you would need a request for an opinion from the patient’s primary care provider before you could bill for a consultation. Depending on the payer, you don’t necessarily need a letter from the other provider, but there should at least be a note in the record that “Patient is sent by Dr. XYZ for evaluation of abc condition.”

After the visit, a consultation would entail a written report back to the requesting physician explaining the opinion that was requested.

For these reasons, you should not code this as a consultation, but rather, may use a new patient code from among 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …).