You Be the Coder:
Outpatient Surgery Patient Is Admitted
Published on Sat Feb 01, 2003
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Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: The surgeon referred a patient having outpatient abdominal surgery to her primary physician for a preoperative consult. While operating, the surgeon found an abdominal aneurysm and called our primary physician back in for a consult to re-evaluate her following surgery. After the evaluation, the surgeon asked our primary physician to manage her postoperative care. How should I code this? She was still an outpatient when our doctor saw her, but he admitted her. Would this be an outpatient service? Would he really be performing a consult if he admitted her upon examination? Can I bill both a preoperative and a postoperative consult?
Maryland Subscriber
Answer: This scenario raises several codingissues. First, regarding the question of coding a preoperative exam, Medicare permits a preoperative consultation for a new or established patient performed by a physician at the request of a surgeon, if the service meets all the requirements for a consultation and you can show medical necessity for the pre-op exam. The last phrase of that sentence is critical. If the patient is not being followed for a chronic illness (for example, diabetes, asthma or hypertension) that may influence the decision to proceed with surgery, insurers will likely not pay for the pre-op exam. The physician must document that the pre-op exam is "medically necessary," or insurers may not cover it.
The second issue is how to code the follow-up visit after surgery. According to Section 15506 (F) of the Medicare Carriers Manual, you should not use the consultation codes if "subsequent to the completion of the preoperative consultation, the consultant assumes responsibility for the management of a portion or all of the patient's condition(s) during the postoperative period." This section also notes that you cannot use a consultation code for a postoperative consult if the physician provided a preoperative consultation for the same patient.
So, in the scenario outlined in the question, the physician cannot bill a consultation code. The post-op evaluation of the patient fails to meet the criteria for a consultation in two key areas. First, the physician assumed responsibility for the care of the patient after surgery. Second, the physician had already provided a pre-op clearance and therefore is not allowed under Medicare rules to bill also for a postoperative consultation.
Instead of using the consultation codes, the physician should bill the follow-up visit with the appropriate inpatient service code. You can do this because the surgeon initially planned the procedure as an outpatient service, and the doctor made the decision to admit only after the surgery. Code using an initial hospital care code (99221-99223) if the surgeon did not handle the admission. If the surgeon transferred care after admitting the patient, use a subsequent hospital care code (99231-99233).
You need to consider one more factor in selecting a code. If the doctor performed the initial consultation several days prior to the surgery and billed it as a 99245 consultation the highest level and performed a history and physical on the day of admission that was less than comprehensive, then you should bill the lowest-level initial hospital care (99221), according to Section 15505.1 (E) of the Medicare Carriers Manual. | |