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.
Latest posts by John Verhovshek (see all)
- The Difference Between Internal and External Coding Audits - August 17, 2018
- Learn More: 2019 Medicare Physician Fee Schedule Proposed Rule - August 17, 2018
- Unrelated Evaluation and Management During a Postoperative Period - August 8, 2018