Part B Insider - 2018 Issue 5
Reader Question: Choose Code Carefully in This Post-Procedure Scenario
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Article Overview
This article answers a reader question about how to think about a postoperative evaluation requested by a surgeon when an anesthesiologist determines a patient is not an appropriate candidate for a proposed intervention. It explains the general documentation and payer considerations involved in reporting a consult and discusses how the setting and timing of the encounter may affect selection within inpatient evaluation and management code families. The piece is relevant to anesthesia, hospital-based coding, and billing staff reviewing consult scenarios.
Why This Topic Matters
Post-procedure consult scenarios can be difficult to classify correctly, especially when the requested evaluation is separate from the original service and documentation must support the reported encounter type. Understanding the broad distinctions discussed in the article can help coders and billers assess whether the visit may be reportable and which inpatient E/M family is implicated.
What You Will Learn
- How a postoperative requested evaluation may be viewed for coding purposes
- What general documentation elements support reporting a consult
- How encounter timing and prior involvement can affect inpatient E/M category selection
- What payer acceptance considerations may be relevant in consult reporting
Who Should Read This
- Anesthesiologists
- Hospital coders
- Medical billers
- Revenue cycle staff
- Physician practice managers
Codes Discussed
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