Consultation Codes


Hastings, MN
Best answers
I have come across a situation where someone has stated that all the Pre OP Exams (POE) should be billed as consultations rather than office visits. I don't agree. Just because the treating physician has sent the patient for a POE
( PA is providing the service) that this constitutes a consultation code! Ant thoughts?
Pre Op

At my job, when we enter codes for pre op exams as office visits there is no referring physician involved. If this is the patient's PCP then it would not be a consult. Either an established patient code or a new patient code if the patient has not seen the doctor in 3 years. A desicion for surgery modifier would be used if the surgery is done the next day.

The only time you use a consult code is when there is a referring physician. There must be documentation by the first doctor stating that they need someone else's opinion.

If the patient decided to get a second opinion from another doctor for surgery then it would be a new patient code and not a consult code:D .
If the patient is referred by the surgeon to the PCP for pre-op clearance, this can be coded as a consult as long as the PCP responds to the referring surgeon with his/her opinion. The PCP is rendering an opinon on the patient's health, medically clearing them for surgery or not. The diagnoses reported should first be the reason for the surgery, then the appropriat V code for the pre-op, followed by any diseases the patient may have (diabetes, hypertension, etc).:)
Thank you for responding to my question. I really appreciate being able to use this forum and that there are folks out there willing to help!

Sonia Metzger
Blue Cross Blue Shield of Minnesota
Special Investigations Unit
Pre-Op Consultations

CMS guidelines state the following. Please refer to the MCPM for further details. (Preop clearance can be coded as a consult if there is a requesting provider...NOT a referring provider). Hope this helps! :)

Medicare Claims Processing Manual
100-04, Chapter 12 - Physicians/Nonphysician Practitioners
Section 30.6.10 - Consultation Services (Codes 99241 - 99255)
(Rev. 788, Issued: 12-20-05, Effective: 01-01-06, Implementation: 01-17-06)

Subsection G. Consultation for Preoperative Clearance
Preoperative consultations are payable for new or established patients performed by any physician or qualified NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening.

Reminder: All consultations are required to have a request, reason and report.
That is correct - I used the wrong term (referred vs requested). All consultations require a request, rendering of the service and a report back to the requesting provider.:D