Pre-Op Clearance Eval E/M?

Kiracodes

Networker
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Noblesville, IN
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This is actually a question on a personal bill I received so I don't have access to the documentation yet. Here's the just of it.


Commercial CMO payer

Outpatient Surgery was scheduled 3 months in advance.

Hospital contacted us a month prior to scheduled surgery to set up an appt for a Routine Pre-surgical Assessment at their Assessment Evaluation Dept. This was done 2 weeks prior to surgery. During the visit a nurse took an extensive history, drew pre-op labs, gave hibecleanse. During hx it was mentioned there was a DVT after another surgery done 2 yrs prior with no further hematology follow-up since. Labs were cleared. NP came in, explained what medication can/can't be taken prior to surgery. Small exam of area that will be operated on but again I can't see documentation yet. Sent home.

Surgery that was done 2 years prior was done exactly identical but did not have an E/M billed.

This time a consult code was billed? Is this appropriate? Should a code even be billed?
 

CodingKing

True Blue
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3,955
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Definitely not a consultation no 3R's here. Sounds like standard pre-op to me which is bundled. Maybe if there was documentation that patient was sent for a full eval due to past history of DVT once could bill an E&M but no way this qualifies as a consult.
 
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