Pre-Procedure H&P Is Bundled to Surgery, Decision for Surgery Is Not

As a general rule, an E/M service provided on the day of, or the day prior to, a major surgical procedure is included and paid for within the global surgical package of that procedure—unless the E/M service, itself, leads to the decision to perform surgery. Stated another way: A routine history and physical (H&P) prior to surgery isn’t paid separately, but the E/M service at which the decision to perform surgery is made is paid separately.

In the latter case, you may report the E/M service using the appropriate E/M service code (e.g., 99202-99205), with modifier 57 Decision for surgery appended.

Chapter 1 of the National Correct Coding Initiative Policy Manual for Medicare Services explains:

If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.

For example, a patient presents to the emergency department with an acute appendicitis and is taken to surgery. The surgeon performing the surgery may report an E/M service code for the evaluation and history and physical. Modifier 57 is appended to the E/M service code to indicate the E/M is not included in the surgical package.

The above policy has been reinforced for 2015 by new text, added to the CPT® codebook surgery guidelines, which state, “Evaluation and management services subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)” are “included in addition to the operation per se.”

For example, a patient is seen on Feb. 1 and scheduled for surgery on Feb. 15. The surgeon sees the patient again for an H&P on the day of the surgery. Although you may report the Feb. 1 visit (with no modifier attached, as it occurs well in advance of the surgery and, thus, would not be included in the surgical package), you would NOT separately report the H&P on Feb. 15 because the decision for surgery was not made at that visit. Rather, the Feb 15 visit would be bundled into the surgical package.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

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John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

2 Responses to “Pre-Procedure H&P Is Bundled to Surgery, Decision for Surgery Is Not”

  1. Kim says:

    Where in CPT book does it state that it’s bundled?

  2. New Private Practice Ophtho says:

    Please help with this scenario:

    Pt is referred to ophthalmologist for a cataract eval by an optometrist or even a pcp. At the eval visit the ophthalmologist diagnosed cataracts and scheduled the patient for surgery 4 weeks later. The ophthalmologist’s sx scheduler helps set up the other preoperative appts for the Pt that same day, right after the appt (h&p, iol measurements, pre open appt with ophthalmologist and pre registration appt with sx center or hospital).
    Is the ophthalmologist required to do the h&p for the patient, or are they able to set up an appt with the pt’s current pcp? If they are able to set up the h&p with the pcp, is the ophthalmology office required to pay for that h&p (because it is suppose to be lumped in the all the sx billing), or does the pt have the pcp bill the their medical insurance provider?
    We have been getting several different answers from several doctors in town. Would like to know the correct procedure to bill appropriately. Where we trained for residency and in the town I am currently in ophthalmologist does not do the h&p (including labs, ekg, and referral to cardio if needed) required before any sx.
    Please include codes and any applicable modifiers. Thank you for your help.

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