General Surgery Coding Alert

Before you even consider reporting any consult service 99241-99263, you must meet (and document) three basic requirements:

1. A physician or other appropriate source must request the consultation (unless the service is a patient-generated confirmatory consultation). The performing physician must document the request.

2. The consulting physician must document his visit with the patient and render an opinion regarding the patient's condition.

3. The consulting physician must prepare a written report of his findings to be provided to the requesting/referring physician (this can be recorded in the shared patient record for inpatient consultations).

Remember: A consulting physician may initiate treatment and/or provide diagnostic testing and still report a consult. But if the physician accepts primary responsibility for the patient, a transfer of care has occurred, and you should report a new or established patient visit, depending on the situation and setting.