General Surgery Coding Alert

Question: Our surgeon has documented that he received a request from another surgeon for an intraoperative consultation for a patient with extensive endometriosis in the pelvis and adhesions to the colon. Our surgeon dictated, "I evaluated the colon by instilling normal saline in the pelvis and then the circulating nurse insufflated the rectum with air. There was no leakage with air bubble testing.

The patient had an endometrial implant on the ileum, and I lysed a few superficial adhesions that were kinking the ileum and could lead to an incomplete bowel obstruction. I then left the operating room theater." Should we code a consultation and a procedure?

Missouri Subscriber

Answer: You should not code both a consultation and a procedure for this scenario. As the documentation stands, the only thing you could code for is lysis of adhesions, depending on what procedure the other surgeon bills.

Unfortunately, lysis of adhesions is almost always a bundled service and not separately payable. That means the only way your surgeon could get paid for the lysing the adhesions is by billing the procedure as a co-surgery, which is often difficult to arrange with another surgeon.

Consultation conundrum: In theory, you could report a consultation code, but one of the problems with intraoperative consultations is that surgeons often don't adequately document the service, as in this case. To code this as a consultation, the surgeon would need to amend the documentation by adding a description of a few additional elements that he performed.

Since consultation codes require documentation of history, exam, and decision making, the surgeon should add that the patient was already under general anesthesia when he was called to the room and all information was received through the other surgeon. This would allow you to count a comprehensive history (which you can do if the patient is unable to answer questions). The surgeon would need to indicate the appropriate exam level, such as problem focused. To document assessment and plan, you can use the information about the decision to lyse the adhesions. Documenting the case in this way would lead to choosing the appropriate inpatient consultation code from the range 99251-99255, (Inpatient consultation for a new or established patient ...) for a non-Medicare patient.