Anesthesia Coding Alert

Question: What documentation is necessary to perform and bill a postoperative pain consult? Is a consult request by the surgeon required?

Nevada Reader

Answer: The documentation required from the surgeon when requesting a postoperative pain consult (99241-99245, office; 99251-99255, hospital) is usually a note in the inpatient or surgical medical record.

Some facilities use specific consultation request forms. When the surgeon telephones the unit/floor and requests the consult (on an inpatient), this is documented and signed in the Kardex and later written in the medical record.

If the pain consult is requested immediately following surgery, the request is documented in the surgical record. If the surgeon requests a postoperative pain consult for his or her patient following discharge, however, the following three criteria must be met to bill for a consultation:

1. The request for consultation must be from another physician or other appropriate source;

2. The request must be documented in the patients record; and

3. Formal communication must be made back to the surgeon from the consultant.

Particularly when an outpatient consult is billed, be certain that a transfer of care has not occurred or that the consulting physician has not taken over care of the patient. Many physicians dispute this, believing that they can bill for a consult because they are only treating a specific problem and not taking over the patients care entirely. This, however, is not the case. Medicare states that a consulting physician can treat (in an emergency) or order diagnostic tests to help render a decision, but he or she was asked for a consult or to evaluate only. In outpatient pain management, the patient is generally referred and should be billed as a new outpatient evaluation. Phrases such as evaluate and treat, consult and treat or refer for series of epidurals are not consults.

Medicare has targeted pain management consultations for careful scrutiny.