tci E/M Coding Alert - 2018 Issue 5

Reader Question: Choose Code Carefully in This Post-Procedure Scenario

Question: A surgeon requested that our anesthesiologist evaluate a patient regarding postoperative epidural insertion. The anesthesiologist felt the patient was not a good candidate for the catheter and recommended using oral pain medications instead. Can we report a consult for this encounter? Massachusetts Subscriber Answer: Your anesthesiologist saw the patient for a new reason – not the reason for the original procedure/encounter. As long he or she completed a history and physical and made a treatment recommendation, you should be able to report a consult (presuming consultation codes are accepted by the payer and you have sufficient supporting documentation)...

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