Quick Tip: Pre-surgical H&P Is Included in Global Package
Per CPT® guidelines, a history and physical performed subsequent to the decision for the surgical procedure is included in the global surgical package. Do not report a separate evaluation and management (E/M) service for the history and physical unless the decision for the surgery is made at the same encounter, on the day of or day before the surgery.
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 Decision for surgery is appended to the E/M service code to indicate the E/M is not included in the surgical package.
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