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General Surgery Coding Alert

Reader Question:

Document E/M Components for Consultation

Question: One of our surgeons was called into a surgery-in-progress to consult on a possible rectal injury. How can I capture this "consultation" service? Texas SubscriberAnswer: The answer depends on the documentation. If the intraoperative consultation is written like a consultation note, then you should choose the appropriate consultation code based on the level of work, such as 99251 (Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making ...). If the physician documents that the patient was already asleep when he entered the room, gives nominal history based on the record or on the other surgeon's comments and then documents his examination of the area(s) in question along with his/her conclusions, a consultation code is most appropriate.Proviso: If the payer doesn't accept consultation codes (like Medicare), then an inpatient or outpatient E/M [...]

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