Reporting initial consult with surgeon when it results in scheduling surgery

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(I am posting this after reading "Report Presurgical H&P With Caution" in January 29, 2013, AAPC News.)

After reading the above article, I have a question similar to Dawna's. I'm not seeing where her question was clearly answered. The above article addressed billing out initial consults when surgery is performed.

To summarize, her post stated in part, "Just trying to understand the difference between preop visit and initial visit. I work in a general surgery practice...We have consults and self referrals and the visit always involves figuring out what is going on and if the patient is a candidate for surgery....Why would you not be able to bill for this?"

The majority of the patients at my surgeon's office are referrals from another physician for a particular issue; for example, we see A LOT of abdominal pain patients. In most cases, the referring physician is referring for a consult to determine etiology of abdominal pain, NOT referring directly for lap chole or appy or whatever the case may be. In these cases, evaluation by our surgeon is mandatory to determining next step in the patient's workup, whether that be endoscopy or HIDA scan or CT scan or whatever.

If the patient is scheduled for surgery directly at this initial consult, from what I'm reading in the original article, the initial consult is NOT billable but rather included in the global for said surgery.

If the patient is not scheduled for surgery directly at this initial consult, again from what I'm reading above, this initial consult IS billable.

I guess I'm confused as to when the initial consult is billable or not billable when surgery is scheduled AS A DIRECT RESULT of the initial consult. As there ANY cases when an initial consult with the surgeon would be billed as an E/M when a surgery is scheduled thereafter??

Of course, then there are the ER consults for abdominal pain that culminate in an appy immediately thereafter. We have been billing the consults with a -57 modifier since the decision for surgery was made after the consult. The ER physician does not make the "decision for surgery," therefore the consult with the surgeon is required.

A second scenario is an initial consult for abdominal pain (or anemia or dysphagia, etc.), and that consult results in the scheduling of an endoscopy, something with a 0-day global period. Does this consult allow the E/M to be billed since there is technically no global period on this procedure? In very few instances, the patient is referred to us FOR an endoscopy, usually referred to us for evaluation to determine whether endoscopy is appropriate...if that makes sense.

Can someone help? My main concern is that we have been overbilling initial consults, when they should have been part of the global.

Thank you!
 

dclark7

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In the article the author is speaking about previously scheduled surgeries. The last paragraph addresses unscheduled or emergency surgeries. In your surgeons' case if the patient comes in for a consult and as a result of that is scheduled for (major) surgery within 24 hours of the visit you may biil with a 57 modifier. If your surgeon sees that patient, schedules surgery and then has the patient return for a "pre-op H& P" then you may not bill for the 2nd visit.
 

nyyankees

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I think it will all fall under what is documented in the note. If docs does an H&P and in his assessment feels the patient needs surgery I would bill it.
 
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In my case, my GI specialist referred me to a surgeon to have my gallbladder removed because my HIDA scan came back abnormal (biliary dyskinesia). I saw the surgeon and we talked about the surgery process and stuff however he is billing me for consult in which it should be part of the global package. It is not like I was sent to him because my GI specialist needs help in figuring out what's going on with me. Does anyone have any input please. Thanks
 
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