Wiki Pre-op consult


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The practice I am affiliated with currently bills consultation codes for their patients when being seen pre-operatively for surgical clearance.

When the encounter dictation indicates the patient is being seen pre-operatively and the only information indicated are diagnoses being treated or monitored to include the reason for the surgery with no hx, ros or pfsh and to refer to the details of the consult dictated at the hospital, no E/M code can be reported correct?

I want to make sure I am thinking correctly before I take this to the provider.

Any assistance with this matter is greatly appreciated.

Karolyn P
If I am reading this correctly, your physician is also dictating at the hospital for that same date of service?? Even though its being dictated to the hospital system, shouldnt you be able to use it for supporting documentation??
Pre-op consultation

There is no dictation for this encounter to support billing an e/m level. The only documentation reported is the patient is here for pre-op eval for surgery, list of diagnosis codes and a reference to the hospital dictation regarding the consult. The hospital dictation reports the exam, history, mdm but is not dated the same date at the office encounter.

We cannot use that dictation to support the e/m visit in the office on a different day correct?


You can code a consultation if requirements are documented: request from surgeon needing preop clearance, reply of findings/recommendations to that same surgeon. Use V72.83 as primary diagnosis and reason for surgery as the secondary diagnosis (or vice versa depending on insurance). Hope this helps.
Pre-op consultation

Thank you, but my concern is if the documentation in the office file only indicates the patient was there for pre-op clearance at the request of Dr.X for surgery on XXX date followed by a list of diagnoses that are being managed by my provider and then refers you to the hospital dictation for details of the consultation.

I want to make sure I am correct in not being able to bill for the office consultation when the documentation in our file does not meet any of the key components and the provider refers you to the hospital dictation.

Hope this makes more sense.

Looking forward to clarification of my thinking.


If the patient was seen in the office that day for a consult and if it meets the consultation requirements then yes, you can code a consult. Did your physician consult in the office and just dictate to the hospital line or was the patient actually seen in the hospital? If patient wasn't actually consulted on at the office then I don't think you can code consult. If consult was done at the hospital then it would be part of the hospital admission. Hope that makes sense. :confused:
kpennington - If I'm understanding the question, I think you are saying that your doctor writes a note in your office chart that the patient is being seen for pre-op clearance and lists the chronic diseases. IF your doctor then indicates that he/she has dictated on the hospital line AND you obtain a copy to keep in your chart, AND all the requirements for a consult are met (request/render/report), you should be able to code for the consult in the office, since the service was provided there. I would strongly encourage the doctor to dictate the note the same day as the consult and make sure the hospital sends a copy for your office chart. If the date of the consultation and the date of the dictation don't match, make sure that the dictation states the actual date of the consult. Does this help?
Pre-op consultation

Thank you for all of the input. Yes my concern was the office note did not reflect the information dictated in the hospital system. I need to review my dates of when the H&P are dictated as related to the office consult.

If the H/P is dictated on a separate date from the office consult then I don't think an E/M level can be billed.

Thanks again.