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Consult vs pre-op by members of same group practice

  1. Default Consult vs pre-op by members of same group practice
    Clearnace Sale
    This scenario is for non-Medicare patients. An OB-Gyn physician (Dr. A) sees a patient who has a pregnancy complicated by Trisomy 21. She is referred to another OB-Gyn physician (Dr. B) in the same group practice but who specializes in Family Planning. She is referred for discussion regarding medical/surgical termination of pregnancy or expectant pregnancy. After Dr. B. spends time counseling the patient on their options, if the patient decides to terminate, Dr. B will perform the surgery the following day. If the patient decides to keep the baby, then the patient returns to Dr. A to continue with her pre-natal care.

    Can Dr. B bill for a consult since both OB-Gyn physicians have different sub-specialties? Or should Dr. B bill for a new patient (based on different sub-specialty) or established visit (based on same group practice?)

    Also, if the patient decides to go ahead with surgery (D&E) the following day, can Dr. B bill for the visit before surgery or is this considered a pre-op visit?

    Thank you.

  2. #2
    Is this a recognized subspeciatly? If so, I would say this is a new patient visit. The originating provider isn't asking for an opinion they are expecting this provider to take over unless the patient decides to continue the pregnancy.

    If they decide to have the procedure within 24hrs of the visit you would just add the 57 to the visit. I wouldn't consider this included in the procedure. Now if they schedule the procedure for later on and see them again, that would be included.

    Just my opinion,

    Laura, CPC, CPMA, CEMC

  3. Default
    Thanks, Laura. The D&E (59840) has a 10-day global period. Therefore, since the pre-op visit for minor procedures (0 to 10-days) starts on the day of surgery and if the D&E will be performed the following day, the E/M visit will not require a modifier 57 (90-day) nor 25. The E/M will require a mod-25 if the D&E was performed on the same day.

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