General Surgery Coding Alert

Now it's your turn to apply the three R's and ask the simple questions that help you spot consultations. Take a look at these consultation scenarios and see how your coding stacks up against the experts. Scenario 1: After an abnormal mammogram, a 46-year-old woman's primary-care physician (PCP) sends her to a surgeon, who examines the patient and reviews the mammogram. The surgeon also performs ultrasonography in the office, followed by an aspiration. In this case, the surgeon may bill for an outpatient consultation (99241-99245) as long as the PCP requests the surgeon's opinion in writing, the request is noted in the patient's medical record, and the surgeon provides the PCP with a written report, says Arlene Morrow, CPC, a general surgery coding, reimbursement and compliance specialist in Tampa, Fla. It's important that the practice retain the consultation request in the patient's files, in case Medicare asks to see it.

A consult, rather than a new patient visit, is appropriate here, Morrow says, because the course of treatment (the aspiration and any subsequent breast surgery) was unknown before the surgeon examined the patient (including the ultrasonography) and reviewed the mammogram's results. The ultrasonography and the aspiration should be billed separately. Scenario 2: The surgeon sees a male patient, 78, for inguinal hernia repair at the attending PCP's request. The surgeon then schedules the patient for surgery later in the week to repair the hernia. Because the PCP correctly identified the patient's problem and directed the surgeon to schedule the patient for surgery, a consultation should not be billed. PCPs have been known to misdiagnose inguinal hernias, so the surgeon appropriately performed a thorough reexamination to confirm the hernia. The visit should be reported using the appropriate-level new patient visit code, 99201-99205.

If the surgeon examined the patient and determined that a hernia repair was not indicated, he or she could report an office consultation (assuming the documentation requirements for a consultation are met) because the surgeon did not carry out the PCP's instructions. Scenario 3: A PCP sends a male patient, 34, to the surgeon for removal of benign skin lesions. Although the surgeon likely performs a short, preoperative evaluation of the patient, the surgeon's only billable service in this situation is the removal of the lesions, 114xx, Mueller says. As in scenario 2, the PCP did not request the opinion of the surgeon (and, unlike scenario 2, in this case there was no need to do so), which means the consultation criteria were not met. The examination performed by the surgeon is included in the lesion removal and should not be reported separately. Get the Most out of Inpatient Consultations CPT includes two sets of inpatient consultation codes, [...]