tci General Surgery Coding Alert - 2012 Issue 8

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...

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