Wiki Pre-op to E/M?

[caskln1]

I work in a large Ortho practice where the surgeons do a lot of hip and knee replacements. They will send the patients with comorbidities out for a pre-op clearance to be done by the PCP YET have the patient come back into our office a week or so prior to the surgery to go over the complications, risk and such. Because there is NO change of condition with this visit, the decision for surgery has already been made and the surgery scheduled we don't charge an E/M for these visits. If the patient is coming in for one of these "pre-op" visits and the surgery gets cancelled, would it be appropriate to code an E/M?

Thank you in advance!

 

[1formissy]

I work in a large Ortho practice where the surgeons do a lot of hip and knee replacements. They will send the patients with comorbidities out for a pre-op clearance to be done by the PCP YET have the patient come back into our office a week or so prior to the surgery to go over the complications, risk and such. Because there is NO change of condition with this visit, the decision for surgery has already been made and the surgery scheduled we don't charge an E/M for these visits. If the patient is coming in for one of these "pre-op" visits and the surgery gets cancelled, would it be appropriate to code an E/M?

Thank you in advance!

You can charge for an E/M if the surgery is cancelled, but there needs to be a signficant reason as to why the patient is coming in. Whenever I audit E/M's, (which is daily) not only am I looking at the systems in the documentation, I also look to see why the patient was coming in for the visit. It's not my role to tell the provider how to treat his/hers patients, but on a coding perspective, the documentation must also support the medical necessity for the service to be reported.
HTH