Orthopedic Coding Alert

Question: Is a consult fee an opinion only in either the hospital or office situation? If the physician is transferring care to our facility, do we bill for consultation or a new patient if we are scheduling surgery or assuming the patients care?

Julie Kirchoff
Garden City, Kan.

Answer: Briefly stated, CPT defines a consultation as a service provided by a physician whose opinion or advice is requested by another physician regarding the evaluation and/or management of a specific problem. Although the consulting physician can initiate diagnostic or therapeutic services, once he or she assumes responsibility for management of part or all of the patients condition, he or she is no longer a consultant and cannot report a follow-up consultation code.

To answer your first question, a consultation can be more than an opinion only because the consultant is permitted to order diagnostic studies. For example, a 77-year-old male is admitted to the hospital by his primary physician after a syncopal episode. Upon admission, the patient complains of severe left hip pain. The physician asks an orthopedic surgeon to evaluate the patients hip pain. The orthopedist examines the patient, reviews x-rays of his hip, determines that he has an intertrochanteric fracture, and schedules the patient for surgery on the following day. Can the orthopedic surgeon bill for a consultation? Absolutely yes. He or she should report the appropriate level initial inpatient consultation code (99251-99255) with modifier -57 (decision for surgery) appended.

If your orthopedist is admitting a patient who is being transferred from another facility, he or she should report the appropriate level of initial hospital care (99221-99223). Once your orthopedist schedules the patient for surgery and assumes his or her care, he or she is the attending physician and not a consultant.