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Inpatient Consultations

  1. #1
    Default Inpatient Consultations
    Exam Training Packages
    I have a question regarding inpatient consultations. Our physician consulted on an inpatient and in the initial consultation note did not indicate surgery. Later the same day, he saw the patient for neurological decline and indicated surgery in that follow up note. He then performed urgent surgery that same day. I am not sure how to code this. Can multiple visits the same day be combined for a consultation? If not, I am unsure how to code this? Any help is appreciated.

  2. #2
    North Carolina
    I would combine the two notes so that you can determine the correct consultation level and to also capture the "decision for surgery" documentation.

  3. #3
    Seattle First Hill
    I agree with Rebecca. Also, make sure you add a -57 modifier, decision for surgery, to the E/M.

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