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Thread: Inpatient Consultations

  1. #1
    Join Date
    Apr 2007

    Default Inpatient Consultations

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    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
    Join Date
    Apr 2007
    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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