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General Surgery Coding Alert

Reader Questions:

Use Documentation to Distinguish Consultation, Co-Surgery

Published on Wed Sep 22, 2010

Question: Our surgeon has documented that he received a request from another surgeon for an intraoperative consultation for a patient with extensive endometriosis in the pelvis and adhesions to the colon. Our surgeon dictated, "I evaluated the colon by instilling normal saline in the pelvis and then the circulating nurse insufflated the rectum with air. There was no leakage with air bubble testing. The patient had an endometrial implant on the ileum, and I lysed a few superficial adhesions that were kinking the ileum and could lead to an incomplete bowel obstruction. I then left the operating room theater." Should we code a consultation and a procedure?Missouri SubscriberAnswer: You should not code both a consultation and a procedure for this scenario. As the documentation stands, the only thing you could code for is lysis of adhesions, depending on what procedure the other surgeon bills. Unfortunately, lysis of adhesions is almost [...]
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