Understand E/M Billing for Preoperative Visits
Question: Our surgeon saw a patient in the office, evaluated their condition, and scheduled surgery. The patient then returned the day before the procedure for a routine preoperative evaluation, and there were no changes in the patient's condition since the initial visit. Can the surgeon bill a separate evaluation and management (E/M) service for that pre-op visit, or is it considered part of the surgical package? Minnesota Subscriber Answer: This is a common source of confusion for many coders and has to do with separate E/M billing. The answer will usually depend on the payer. For payers such as Medicare that have global surgery guidelines, you must bundle certain services before and after the surgery based on the rules for the appropriate global period of the codes you are billing. For example, under Medicare rules, once the provider makes the decision for surgery, you should not separately bill any preoperative visits related only to the surgery. In other words, the prescreening visits don’t usually present new information to warrant the need for an E/M service. If the patient’s situation changes between the first and second visits before surgery, however, you may be able to make the case for billing another office or outpatient E/M. For instance, if the patient develops a serious medical condition that is unrelated to the reason for the surgery, but could impact the outcome, the surgeon may perform additional services that increase the level of medical decision making (MDM) and, if properly documented, could allow you to bill a separate E/M visit. Make note: You’ll need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) when there is a separately billable E/M. Documentation must clearly support the separate service, and you’ll need to include a detailed paragraph for the payer as to why the services are deemed necessary and separately billable. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
