Wiki Pre-procedure

[RABBIT2020]

Is this considered separately billable on the day of the procedure?
If it is billed and reimbursed is it still correctly coded?
On 16th the patient presents with missed abortion. Plan of treatment was discussed and outline. Patient opted for office procedure of Manual vacuum aspiration.

On the 17th patient presents for procedure.
Note for Pre-procedure is this:
Reason for Appointment: Pre-procedure
HPI: in for consent preoperative medications in anticipation of office MVA for missed AB
Assessment: SAB o02.1
Treatment: List of all the pills to be taken were outline on the note.
Clinical notes: 30y/o G1 PO @ 7 week sized MAB for office MVA; entire procedure reviewed and patient associated risks of bleeding and infection identified; consent signed and witnessed; medicated with xxx, xxx, xxx and xxx to proceed with MVA as arranged in 1-2 hours.

Time spent on the patient encounter today 30 mins. 99214-25

There is another note for the procedure. 59820

MY question is the above billable given the sequence of events and given it is part of the procedure and given it was not a separately above and beyond what the patient was scheduled for on the day of the procedure?

 

[CBLENNIE]

If your question is about billing 99214-25 on the 17th, which is the same day the 59820 procedure, then it would not be appropriate because the office visit note indicates the E&M service was specifically related to the surgical procedure which was scheduled the day before on the 16th.

I would think an E&M was billed for the 16th with modifier 57 because that is when the decision for surgery was made and that would be the only separately reimbursable E&M procedure in based on your post. I work for a payer and if we audited services billed on the day of surgery and found 99214-25 and 59820, we would not allow the 99214-25 because the decision for surgery was made previously and the E&M is not supported based on the note provided.