General Surgery Coding Alert

There is more to reporting consultations than ensuring the general surgeon has fulfilled the three R's. You must also consider other factors that greatly affect reimbursement, such as location of service, transfer of patient care, and whether the patient's condition was known before the consult.

Like all medical specialists, general surgeons consult in a variety of situations:

1. A primary-care physician (PCP) asks a general surgeon to evaluate a patient.

2. The emergency department calls the surgeon to assess a patient.

3. The surgeon is requested to see an inpatient.

4. Another specialist performing a procedure requires the general surgeon's expertise to assess a patient.

To bill a consult in any of these situations, you must meet certain criteria established by CMS and CPT.

According to CPT, "a consultation is a type of service provided by a physician whose opinion or advance regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source The written or verbal request for a consult may be made by a physician or other appropriate source and documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source."

Section 15506 of the Medicare Carriers Manual (MCM) outlines three basic consult requirements: request, review and report.

1. A consultation is distinguished from a visit because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record.

3. After the consultation is provided, the consultant prepares a written report of his/her findings, which is provided to the referring physician.

Adhering to these criteria alone, however, does not necessarily mean that a consult should be billed. A consultation may not be billed when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance, the MCM states.

The issue greatly affects reimbursement. For example, the Physician Fee Schedule assigns 3.20 relative value units (RVUs) to a level-three office consultation (99243), but only 2.54 RVUs to the same-level new patient visit (99203).

Many coding experts maintain that the MCM's language, which was revised in August 1999, brings the CMS consult definition closer to the CPT description, which states that "a physician consultant may initiate diagnostic and/or therapeutic services." But this view is far from universally accepted among coding specialists. Until the definition of "complete care" is resolved, the confusion regarding consultations will continue, many experts contend.

Many general surgery practices can cut through the confusion by answering a relatively straightforward question, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. "A consultation may or may not be billed depending on whether the patient's condition is known or merely suspected," Mueller says. "If the requesting physician already knows the patient's problem and the treatment required, and the surgeon is simply being asked to carry out those instructions, a consult should not be billed. If, however, the surgeon's opinion is required before treatment is initiated (or not initiated), the surgeon can bill for a consult, assuming all the criteria for a consult have been met."

The location of the service also affects whether a consult may be billed and, if so, which code should be used to report the service, Mueller says.

And, because of the general surgery's nature, the surgeon may perform a procedure after evaluating the patient. This too may affect how the encounter between the surgeon and the patient is billed, because in some circumstances the surgery may constitute a transfer of care.

If the surgery is performed on the same day, either modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier -57 (Decision for surgery) may need to be appended to the consultation code.