General Surgery Coding Alert

You must have the 'three R's' to report a consult

To test your knowledge of what separates a consult from other outpatient services, take this quick coding quiz.
 
Scenario 1: The patient sees his primary-care physician to complain about sharp pain in his lower abdomen after a recent move into a new home. The patient suspects he may have injured himself lifting boxes. The PCP offers the patient advice to alleviate the pain and recommends that the patient see a surgeon as soon as possible. Three days later, the patient sees the surgeon, who diagnosis the patient with a hernia.
 
Consult, or transfer of care/referral?
 
Solution 1: In this case, you cannot claim a consult because the visit does not meet the minimum requirements of request, render and report.
 
Although the PCP recommended that the patient see the surgeon, he did not specifically request that the surgeon see the patient, nor did the surgeon report his findings back to the PCP. You should report an appropriate-level new patient office visit (for example, 99204, Office or other outpatient visit for the evaluation and management of a new patient...), as supported by the surgeon's documentation.
 
Scenario 2: The patient's PCP requests that the surgeon see a patient with a complaint of rectal bleeding (569.3, Hemorrhage of rectum and anus).
 
The surgeon examines the patient for 40 minutes, taking the patient's history, performing an exam and deciding to perform a sigmoidoscopy - which does not reveal a more serious problem. The surgeon discusses his findings with the patient, notes them in the medical record and prepares a report for the PCP outlining those findings.
 
Consult, or transfer of care/referral?
 
Solution 2: In this case, you should report an office consultation, such as 99243 (Office consultation for a new or established patient ...). Even though the surgeon performed diagnostic sigmoidoscopy, the visit meets all the requirements of a consult.
 
Be sure, also, to report the sigmoidoscopy (for example, 45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consult code.

Scenario 3: A woman meets with her PCP and asks about a lump she recently noticed in her breast. The PCP contacts a surgeon colleague and requests that the surgeon "consult and treat" the patient for potential breast cancer. The surgeon meets with the patient and after biopsy confirms a diagnosis of cancer, and recommends surgery at the earliest date. The surgeon operates on the patient and performs all postoperative care.
 
Consult, or transfer of care/referral?
 
Solution 3: In this case, the initial visit could be either a consult or a transfer of care, depending on documentation.
 
Although the PCP requested that the surgeon "consult and treat" the patient, you may only consider the first visit a consult if the PCP makes the request and the surgeon reports his findings back to the PCP.
 
If the surgeon immediately accepts care of the patient, you should report a new outpatient visit (such as 99204) rather than a consult.