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Question:
An internist sent an elderly patient to our office the other day for evaluation of lower GI pain and bleeding. After evaluating the patient, the surgeon scheduled the patient for a sigmoidoscopy two days from now at the outpatient GI facility in our town. Can the surgeon report this as a consultation even though he is taking the patient for a procedure in two days?
Answer:
The patient was seen by the surgeon for evaluation of lower GI pain and bleeding at the request of the internist. According to the definition of a consult, the appropriate E&M category is a consultation visit. It is appropriate to report the consultation for the first visit (as requested by the internist). Any future visits related to this problem will be reported as an established patient visit assuming the patient is not seen during any post operative global periods. The physician would not need a modifier on the E&M service, because the sigmoidoscopy will be performed two days later.
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