General Surgery Coding Alert

Question: What's the difference between a consult and a referral? How, for instance, would I report the service if my surgeon received a "consult and treat" request from another physician.

Illinois Subscriber

Answer: You may want to clarify with the "consulting" physician what his intent was in sending the patient to your surgeon.

To report a consult code (99241-99255), you must be sure that the medical record reflects all the components that make up a consultation:

1. There must be a request from one physician (or other appropriate source) that your surgeon see the patient

2. The requesting physician must clearly indicate the reason for the consultation

3. The consulting physician (your surgeon) must provide a written report back to the requesting physician that describes his findings, recommendations, etc., on how the requsting physician may continue to treat the patient

Essentially, the requesting physician says to the consulting physician, "You have expertise in this area, and I need a recommendation on how to treat the patient with problem X."

Although the consulting physician may actually assume care of the patient's problem in a subsequent visit (a "transfer of care"), the initial visit occurs for the purpose of providing the requesting physician with specialist advice on how to treat his patient.

A "referral," on the other hand, assumes that one physician is allowing another physician to take over care of the patient (which would also qualify as a transfer of care). The first physician is not requesting the second physician's opinion or advice, and there is no requirement that the second physician share his findings or plans for treating the patient with the referring physician.

To report an E/M visit with a patient who was referred by another physician, you would use the appropriate level new or established, inpatient our outpatient visit code.

Example: A patient arrives at his primary care physician's office with a visible hernia in the lower abdominal area. The PCP immediately refers the patient to a general surgeon for treatment and repair.

In this case -- even if the PCP contacts the general surgeon to recommend he see this new patient, and even if the general surgeon provides updates on the patient's condition to the PCP -- the service does not qualify as a consult. Rather, because the PCP has no intention of resuming care of the patient's condition (instead leaving treatment to the surgeon) a transfer of care has occurred.

The general surgeon would report the initial E/M service using an appropriate new patient code (for instance, 99204, Office or other outpatient visit for the evaluation and management of a new patient...).

However, if a PCP requests a consult with a surgeon for a patient with a suspicious breast lump, the PCP should specifically inform the surgeon that examination of the lump is the purpose of the consult request. The surgeon should indicate that the patient is there at the PCP's request for the surgeon's opinion on the suspicious breast lump.

Consider, instead, a scenario in which the managing physician requests that your surgeon provide a consultation for a hospital inpatient complaining of rectal bleeding (569.3, Hemorrhage of rectum and anus). The surgeon documents the request, examines the patient and shares his findings, along with a suggested plan of care, with the managing physician.

In this case, you should report an initial inpatient consult (for example, 99254, Initial inpatient consultation for a new or established patient ...), as well as any diagnostic tests the surgeon provides (for example, 45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Don't forget: You must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consult code in this case because the surgeon provided a same-day procedure.

-- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program.