Wiki E/M codinf


Mckinney, TX
Best answers
Office visit vs. Consultation

If a patient comes for a preop evaluation visit to the PCP ( not the Surgeon )before the surgery takes place, should it be a office visit with the preop diag. or a consult to the PCP.

I would really appreciate the quick response.

IF documentation meets all of the requirements for a Consultation (Request/Render/Report) then you should code a consultation. Use the appropriate V code for the primary dx, the reason for the surgery as the second, and any other conditions addressed as subsequent dx.:)
Is the PCP sending the patient to the surgeon for the surgery? If the PCP is the physician that requested the surgeon's advice/opinion about a situation, and then in turn the surgeon decides a surgery is needed, I would think it would be an office visit. I don't see the medical necessity in a consult.

On the reverse, if another physician sent the patient to the surgeon, and the surgeon is requesting preop eval from the PCP, if all qualifications of a consult are met, it may be appropriate.

Any other opinions?
I agree that if the PCP sent the patient to the surgeon, then the service should be billed as an office visit.