Pre-operative evaluation

maine4me

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When our family physicians perform an preoperative evaluation they bill
consultation codes for our non-Medicare patients and the appropriate
E/M code for our Medicare patients. Here is my dilemma, the
physicians often will state in the visit note for ROS, and Exam see
pre-operative form. These forms typically have a check box system
which indicates if the systems have are within normal limits, and if
there is anything abnormal the doctor should note this. Is it
adequate documentation to use the limited information obtained from
the form?

Also, they feel if the form has the doctor's name listed at the top
this is sufficient to meet the request requirement for the consult
codes. My recommendation has been that they indicate that the
preoperative evaluation was requested by Dr. X for whatever surgical
procedure.

Can any one tell me how they handle these types of visits?
 
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