General Surgery Coding Alert

Now it's your turn to apply the three R's and ask the simple questions that help you spot consultations. Take a look at these consultation scenarios and see how your coding stacks up against the experts.

Scenario 1: After an abnormal mammogram, a 46-year-old woman's primary-care physician (PCP) sends her to a surgeon, who examines the patient and reviews the mammogram. The surgeon also performs ultrasonography in the office, followed by an aspiration.

In this case, the surgeon may bill for an outpatient consultation (99241-99245) as long as the PCP requests the surgeon's opinion in writing, the request is noted in the patient's medical record, and the surgeon provides the PCP with a written report, says Arlene Morrow, CPC, a general surgery coding, reimbursement and compliance specialist in Tampa, Fla. It's important that the practice retain the consultation request in the patient's files, in case Medicare asks to see it.

A consult, rather than a new patient visit, is appropriate here, Morrow says, because the course of treatment (the aspiration and any subsequent breast surgery) was unknown before the surgeon examined the patient (including the ultrasonography) and reviewed the mammogram's results. The ultrasonography and the aspiration should be billed separately.

Scenario 2: The surgeon sees a male patient, 78, for inguinal hernia repair at the attending PCP's request. The surgeon then schedules the patient for surgery later in the week to repair the hernia.

Because the PCP correctly identified the patient's problem and directed the surgeon to schedule the patient for surgery, a consultation should not be billed. PCPs have been known to misdiagnose inguinal hernias, so the surgeon appropriately performed a thorough reexamination to confirm the hernia. The visit should be reported using the appropriate-level new patient visit code, 99201-99205.

If the surgeon examined the patient and determined that a hernia repair was not indicated, he or she could report an office consultation (assuming the documentation requirements for a consultation are met) because the surgeon did not carry out the PCP's instructions.

Scenario 3: A PCP sends a male patient, 34, to the surgeon for removal of benign skin lesions.

Although the surgeon likely performs a short, preoperative evaluation of the patient, the surgeon's only billable service in this situation is the removal of the lesions, 114xx, Mueller says. As in scenario 2, the PCP did not request the opinion of the surgeon (and, unlike scenario 2, in this case there was no need to do so), which means the consultation criteria were not met. The examination performed by the surgeon is included in the lesion removal and should not be reported separately.

CPT includes two sets of inpatient consultation codes, initial (99251-99255) and follow-up (99261-99263). Initial consults are reported more frequently.

Scenario 4: The attending PCP admits a 24-year-old osteomyelitis patient to the hospital. After a consultation, the general surgeon decides surgery is not required. Even though the patient has already been diagnosed, the PCP wants the surgeon's opinion on how best to treat the patient. Therefore, the surgeon may bill the appropriate-level initial inpatient consultation code as long as the chart contains a written request for the surgeon to see the patient.

A separate report is not required in the hospital setting, according to section 15506 of the Medicare Carriers Manual: "In an emergency department or inpatient or outpatient setting in which the medical record is shared between the referring physician and consultant, the request for consult may be documented as part of a plan written in the requesting physician's progress note, an order in the medical record or a specific written request for the consultation. In these settings, the written report required for consult may consist of an appropriate entry in the common medical record."

Scenario 5: This is the same as scenario 4, but the surgeon immediately begins to prepare the patient for surgery. Again, the PCP has asked for the surgeon's opinion, but because the patient is immediately prepared for a surgical procedure with a 90-day global period, modifier -57 should be appended to the appropriate initial inpatient consultation code, Morrow says. By doing so, the surgeon indicates that the consultation was not part of the preoperative evaluation.

Scenario 6: A 53-year-old woman with severe abdominal pain is admitted by her PCP, who asks the general surgeon to perform a cholecystectomy. The surgeon evaluates the patient, confirms the diagnosis and performs the procedure laparoscopically.

In this case, the surgeon should not bill for the consult because the documentation does not indicate that the surgeon's opinion was requested. Had the surgeon's preoperative evaluation revealed that the patient's abdominal pain did not require a cholecystectomy, a consult could have been billed.

The surgeon could have billed a subsequent hospital visit (99231-99233) with modifier -57 as well as the laparoscopic cholecystectomy.

ED consultations are one of the thorniest issues that coders for general surgeons and other specialists face.

Although the MCM states, "if the emergency department physician requests that another physician evaluate a given patient, the other physician should bill a consultation if the criteria for consultation are met," there are several situations when a consultation should not be billed.

Scenario 7: An emergency physician asks an on-call surgeon to evaluate a female patient, 47, who has severe abdominal pain. The surgeon admits the patient and performs emergency surgery.

Many surgeons believe that when they are on-call they automatically perform a consult when they see ED patients. But this assumption is often incorrect. In this case, for example, the emergency physician asked for the surgeon's opinion but likely did not intend to resume the patient's care. Consequently, the surgeon becomes the patient's attending physician and admits the patient for surgery. Therefore, the surgeon may not bill for a consultation. Instead, he or she should report the appropriate hospital admission code (99221-99223).

If the surgeon did not have to admit the patient to surgery and subsequently discharged the patient, an ED code (99281-99285) should be billed, MCM says. Some carriers may not recognize an ED code for the same patient from a second physician on the same day. Because an ED patient is considered an outpatient, the surgeon should use a new or established patient code to bill these carriers.

Scenario 8: A male patient, 67, with acute upper abdominal pain arrives at the ED. The emergency physician, suspecting gallstones, calls for the surgeon, who examines the patient and determines that kidney stones, not gallstones, are causing the pain. The surgeon returns the patient to the care of the ED physician, who calls for a urologist.

In this case, the patient's care was clearly not transferred to the general surgeon because a urologist later examined the patient. Therefore, the surgeon can bill for a consultation. Because the surgeon's examination took place in the ED, which is classified as outpatient, the appropriate outpatient consultation code should be reported. To avoid subsequent audit problems, Mueller says, the patient's medical record should clearly state the emergency physician's full name.

CPT does not include specific codes for intraoperative consultations, so inpatient or outpatient consultation codes must be used, depending on where the procedure took place.

Typically during an intraoperative consult, the surgeon enters the operating room, examines the patient, offers an opinion, and either leaves the room or performs additional surgery, Morrow says. The surgeon's ability to perform a comprehensive examination is restricted because the patient is anesthetized, she adds.

Although a comprehensive (level four or five) history can be claimed if the surgeon notes that the patient was anesthetized and the medical decision-making component was at a high level because the exam took place during surgery, the weakness of the examination portion usually limits the surgeon to reporting a low-level consultation.

Scenario 9: An ob/gyn performing a hysterectomy on a 52-year-old woman accidentally nicks the patient's small intestine and calls in the general surgeon to repair the perforation.

The surgeon cannot bill for a consultation in this case because the ob/gyn does not require the surgeon's opinion. The surgeon enters the operating room only to repair the bowel and, therefore, only this service should be billed.

Note: Repair of the small bowel should be reported as 44602 (Suture of small intestine [enterorrhaphy] for perforated ulcer, diverticulum, wound, injury or rupture; single perforation).

Scenario 10: This is the same scenario as above, but without the bowel perforation. While performing the surgery, the ob/gyn notices an abnormal growth in the bowel and calls in the surgeon to evaluate it. The patient had undergone a bowel prep prior to hysterectomy, and the decision to resect the bowel was made during the consultation.

If the request for the surgeon's evaluation is in the patient's chart, the surgeon may bill for an inpatient consultation, regardless of whether any surgery is performed. In this case, the surgeon executed a colon resection, which means modifier -57 should be appended to the appropriate inpatient consultation code.

Note: When a consultation is performed, the surgeon should avoid using the term "referral," because some carriers, upon seeing this word, decide that a transfer of care occurred. The requesting physician also should not mention "referral," even though this term occurs often in the MCM section on consultations.