General Surgery Coding Alert

Question: Our surgeon was called for a consult while the patient was in observation status, and ended up doing an appendectomy. The patient was discharged in under 23 hours. Should we use the observation codes or the consult codes?

North Carolina Subscriber

Answer: Assuming that the documentation for your surgeon supports a consultation and the payer is not Medicare (or another payer that no longer accepts consultation codes), codes 99241--99245 (Office consultation for a new or established patient ...) are appropriate for the consult. CPT instruction clarifies that these codes are appropriate for hospital observation.

The physician who sent the patient to observation and requested the consult would use the observation codes (99218-99220).

Medicare is different: If this is a Medicare patient, you shouldn't report a consultation code. Instead, you should choose one of the following codes for an E/M service that would qualify as a consult for a patient on observation status:

• 99201-99205 -- Office or other outpatient visit for the evaluation and management of a new patient ...
• 99211-99215 -- Office or other outpatient visit for the evaluation and management of an established patient ...

Don't miss modifier: Because your surgeon decided to perform an appendectomy based on the E/M visit, you should append modifier 57 (Decision for surgery) to the consultation or other E/M code that you report.