Coding for A surgeon

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hi
I'm coding for a surgeon. I need to know when my Dr. goes to see the pt at the hospital for the initial consultation and makes a decision for surgery, is this considered INITIAL HOSP CARE or INITIAL OBSERVATION CARE; also after the pt foes to the office for after care, this is considered a follow up visit?
 

cgaston

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The patient's status should be documented somewhere and you choose your code once you know their status. I have access to the hospital's system so I can see when a patient was admitted and whether it is an inpatient or observation admission.



I code for General Surgeons. The ER doctor usually requests a consultation for all trauma patients but that doesn't mean the visit will end up being billed out as a consultation:

If they only perform their exam and render their opinion I code it as a consultation.

If my doctor decides to admit the patient during the course of his/her examination he/she will state in the note "admit for observation" or "admit to inpatient after surgery" and I will chose admit codes over consultation codes because he/she is the admitting physician.



As for post operative visits, that too depends on whether or not the surgery has zero, 10 or 90 days global periods. If the patient comes for a visit related to the surgery within the global period it is included.

If the patient sees your provider for something unrelated to the surgery within that period the service can be billed with -24 modifier if the documentation supports that the visit is unrelated to the surgery.



There are so many variables to consider that there is no "one size fits all" answer.
 
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Thanks for your reply. I know that if he does a consult, decides to perform a surgery, the post-op visit at the office is a "Established Patient visit",; but if he gets called as an emergency surgery, the patients visit to the office after the surgery. Is that considered an "Established patient" as well; or, do we code this a a "New Patient visit"
 

CodingKing

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Surgery is a face to face service so the patient is now established for all additional E&M services for the next 3 years.
 
Last edited:

Jaslene08

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only if pt is in observation status you bill with an observation code. If not bill under initial hospital code with a modifier 57. When seen in the office patient is now an established patient.
 
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