Otolaryngology Coding Alert

Question:I'm an ENT coder, and I have a question about billing for a consent and history and present illness (H&P) prior to surgery. A recent coding article I read states that a pre-op H&P becomes an "administrative" H&P if the physician made the decision to perform the procedure at another encounter. If the visit is medically necessary, the primary or first diagnosis for the preoperative visit should be V72.84. Is this correct?Florida SubscriberAnswer:In an ENT office, you should include most preop exams as presurgical clearance or, as the article called them, "administrative H&Ps." You should not bill a pre-operative clearance that is administrative as it is not a chargeable service and not payable. If you are performing a pre-op exam for another surgeon, you would code the appropriate V code first and the reason for the surgery second. For instance, in the case of the patient with allergies, you should report V72.82 (Pre-Operative [...]