Wiki Help with Surgical question

[jholt12]

Hi,
I could use some coders input on this question since I have received different answers.

If I have patient that we have never seen but I have the path and I know that I am doing surgery the day that they do come in would you charge a new visit with the surgery? Also before you answer I have been looking into the guidelines and in the definition of a surgical package it states that a related E&M encounter on the date of procedure (including history and physical) is included in the surgical code.

So would I charge the new visit if in the assessment and plan it states see surgical note?

Thanks for you help

 

[mhstrauss]

Hi,
I could use some coders input on this question since I have received different answers.

If I have patient that we have never seen but I have the path and I know that I am doing surgery the day that they do come in would you charge a new visit with the surgery? Also before you answer I have been looking into the guidelines and in the definition of a surgical package it states that a related E&M encounter on the date of procedure (including history and physical) is included in the surgical code.

So would I charge the new visit if in the assessment and plan it states see surgical note?

Thanks for you help

If the decision for surgery has already been made, there's probably not a medically necessary reason to justify billing a seperate E/M service on the day of the procedure; the history and physical done that day would be included in the global surgery charge.

 

[ajs]

Hi,
I could use some coders input on this question since I have received different answers.

If I have patient that we have never seen but I have the path and I know that I am doing surgery the day that they do come in would you charge a new visit with the surgery? Also before you answer I have been looking into the guidelines and in the definition of a surgical package it states that a related E&M encounter on the date of procedure (including history and physical) is included in the surgical code.

So would I charge the new visit if in the assessment and plan it states see surgical note?

Thanks for you help

Although you believe you will need to go to surgery, you have never met this patient nor discussed the treatment options with them. The work up for a new patient is generally more extensive than a regular preop visit with an established patient. I would bill for the E/M, and append the appropriate modifier IF after the exam and discussion with the patient surgery is decided upon. Technically the decision for surgery is not made until you actually meet with the patient face-to-face and review the options.