General Surgery Coding Alert

Remember: 1 consult per inpatient stay is the limit

CPT 2007 has added instructional text to help you decide when you should report a consultation service, and now makes clear that you should not claim a consult if the surgeon assumes responsibility for management of even a portion of the patient's condition(s).

Inpatient Language Changes, Rules Don-t

You-ll find a new definition for inpatient consult codes 99251-99255, but the changes only serve to clarify already standing guidelines.

The new descriptors for 99251-99255 eliminate the word -initial- and now specify simply, -Inpatient consultation for a new or established patient --

-When CPT deleted the follow-up inpatient codes (99261-99263) for 2006, the need to identify 99251-99255 as -initial- became redundant,- says Suzan Hvizdash, CPC, CPC-EMS, CPC-EDS, physician educator for the University of Pittsburgh and American Academy of Professional Coders National Advisory Board member. -Deleting -initial- from the code descriptor seems like a bit of housekeeping.

-The descriptor change doesn't alter the way in which you-ll apply these codes,- Hvizdash says. -You may report 99251-99255 for the surgeon's first visit with the patient per inpatient stay, as long as the service meets all the requirements of a consult. You should report all follow-up facility visits during the same inpatient stay using subsequent care codes.-

CPT 2007 has also added text preceding the inpatient consult codes that explicitly reinforces this advice: -Only one consultation should be report by a consultant per admission. Subsequent services during the same admission are reported using Subsequent Hospital Care codes 99231-99233 or Subsequent Nursing Facility Care codes 99307-99310,- depending on the setting.

Example: 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 with the managing physician.

In this case, you should report an inpatient consult (for example, 99254) and 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 E/M 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.

The next day, the managing physician once again asks the surgeon to examine the patient because of new symptoms. Again, the surgeon documents the managing physician's request, examines the patient and shares his findings with the requesting physician.

For the follow-up visit, claim subsequent hospital care (for instance, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...). Although this visit may look like a consult, you must report subsequent care.

Different Stay = Another Consult Opportunity

Remember, you should report only one inpatient consult per inpatient stay. If the surgeon provides a consult service during a different inpatient stay (whether for the same or a different problem), you may report another inpatient consult code.

Example: The managing physician discharges the patient in the above example on Jan. 5. The following week, the physician admits the patient once again.

And, once again, the managing physician asks the surgeon to provide an opinion on the patient's condition. As long as the service meets the necessary requirements for a consult (that is, the surgeon renders an opinion and reports this back to the requesting physician without assuming the patient's care), you may again report the appropriate inpatient consult code for the encounter.

Second Request Necessary for Additional Consults

You will also find text added to CPT prior to the -Office and Other Outpatient Consultation- subsection that states you may report more than one outpatient consult (99241-99245) for the same patient, for either the same or a different problem. The subsequent visit must, however, meet all the criteria of a consultation service (a request for an opinion and a reason for the request by an appropriate source, and an opinion rendered and a report issued by the consulting physician).

You must report any visits that either the physician or the patient initiates (that is, any visits not initiated by another physician or appropriate source requesting a consult) using standard E/M service codes (such as 99212-99215 for office visits, 99334-99337 for rest homes, etc.).

-These aren't new requirements,- Hvizdash says. -The rules are the same as they-ve been for years. CPT has simply chosen to clarify these points by adding some additional text.-

Example: The surgeon receives a request from a primary-care physician to provide an opinion on a patient with a possible hernia. The surgeon provides the consult and reports 99243 for the service. Several days later, the surgeon sees the patient again at the patient's request. In this case, you must report 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient), as appropriate.

Only if the surgeon had provided the second service at the request of a physician or other appropriate source -- and if the visit met the remaining requirements for a consult -- would you report a second unit of 99241-99245.

Request Must Come From an Appropriate Source

CPT 2007 takes the time to elaborate on the requirement that you may only report a consult if the consult request comes from an -appropriate source.-

Specifically, the AMA added text to CPT that instructs, -A -consultation- initiated by a patient and/or family, and not requested by a physician or other appropriate source - is not reported using the consultation codes but may be reported using the office visit, home service or domiciliary/rest home care codes.-

What is an appropriate source? According to CPT, an appropriate source for a consult request can include another physician, a physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer or insurance company.

This would mean, for instance, that if a patient requests a -second opinion- from your doctor on a diagnosis, you must report the service not as a consult, but as a standard E/M visit.

Example: A patient recently diagnosed with intestinal cancer (e.g., 153.x, Malignant neoplasm of colon) seeks a second opinion before undergoing surgery to remove the affected tissue. Your surgeon provides a full workup and discusses possible outcomes with the patient.

In this case, you should report an appropriate-level new patient visit (such as 99204, Office or other outpatient visit for the evaluation and management of a new patient ...).

Assumption of Care Begins at Second Visit

If the -consulting- doctor begins treatment or otherwise assumes responsibility for managing all or a portion of the patient's condition prior to completing the initial visit, you can still report that visit as a consult (assuming the visit meets the requirements of request, reason, opinion rendered and report). But you must report all subsequent visits using the appropriate established patient E/M services, according to CPT 2007 instructions.

Specifically, CPT language says, -In the hospital or nursing facility setting, the consulting physician should use the appropriate inpatient consultation code for the initial encounter and then subsequent hospital or nursing facility care codes. In the office setting, the physician should use the appropriate office or other outpatient consultation codes and then the established patient office or other outpatient services codes.-

Bottom line: The AMA says that your surgeon can assume responsibility for a patient's care and still report the initial service as a consultation, as long as you have documented the requirements to report a consult service.

Keep in mind: The consulting physician can initiate diagnostic or therapeutic services and still claim a consultation, says American Academy of Professional Coders National Advisory Board member Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHBME. -The consulting physician must perform any relevant, necessary services to give an opinion on the patient's condition -- that's the point of the consultation,- she says.

Example: Let's return to the first example above of the patient with the complaint of rectal bleeding. The surgeon performs a diagnostic procedure (the sigmoidoscopy) and devises a plan of care, which he reports to the requesting physician. In this case, you may report a consultation for the initial service even if the surgeon directs the patient to return to him (rather than the requesting physician) for treatment (that is, even if the surgeon assumes responsibility for care of the patient's problem).

Tip: One way your surgeon can handle assumption of care is to conclude the report to the requesting physician, -Unless I hear from you otherwise, I will proceed with the plan of care as outlined above.- In this way, the consulting physician can assume responsibility for the patient with the requesting physician's tacit approval.

If, as is likely, the patient does return to the surgeon at a later date for treatment, you may report the subsequent visits using the appropriate standard E/M codes (such as 99232 in an inpatient setting).