Part B Insider (Multispecialty) Coding Alert

Document primary care consults the same as specialist ones

If you think consults are just for specialists, think again.

Primary care physicians can provide consults too, say experts. A typical scenario is when a surgeon wants a family practice or internal medicine physician to make sure a patient's health problems are stable enough for the patient to withstand surgery. A patient may also seek out a primary care physician for a "second opinion" before surgery.

Key idea: A primary care consult must be medically necessary and a physician or "other appropriate source" must request it unless the patient requested it herself, according to a Dec. 17, 2004 bulletin by Part B carrier HGS Administrators. As with other kinds of consults, the consulting physician should make a report back to the requesting physician, and the documentation must support the level of care billed.

Also, the consulting physician should have "an expertise and knowledge base over and above the referring physician in regard to the specific nature of the consultation request," HGSA says.

Mistake: Some primary care practices believe they have to attach the 56 modifier (pre-operative management) to their consult codes for a pre-operative consult. You should only use this modifier with surgical codes, however, says Angela Flood, a health care consultant with Coding Compliance Solutions in Birmingham, MI.

To qualify for the 56 modifier, you'd need documentation that shows the surgeon told the other physician to participate in the global period, says Marie West, a coder with the Oklahoma Health Care Authority. The surgeon should ask the other doctor in writing to take care of the patient's preoperative clearance.

Diagnosis codes: You should use a V code, such as V72.84 (Pre-operative examination, unspecified), to show that this is a preoperative consult, says Jan Rasmussen with Professional Coding Solutions in Eau Claire, WI. But the carrier still may not pay your claim unless you also include a diagnosis code that explains why the surgeon requested the pre-operative consult. Tip: Communicate with the surgeon and find out what chronic problems he wanted your primary care physician to evaluate, she explains.

Surgeons shouldn't have primary care doctors perform pre-operative clearance unless a chronic problem requires special attention before surgery, adds Rasmussen. Global surgery fees include preop evaluation on healthy patients, she explains.

Cover all bases: In addition, your claim should include a code that explains why the patient is having surgery, adds Flood. In the case of a knee operation, it might be arthritis of the knee. So in fact, you need three diagnosis codes: the V code, the surgical code and the chronic condition, which could be congestive heart failure or diabetes.