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Pre-procedure E/M


Local Chapter Officer
Best answers
I am a multi specialty pediatric coder coding professional fees (Eval & Mgmt Svcs and procedures) for medical providers who provide services on hospital floors for patients who receive chemotherapy. I have come across documentation for one pediatrician who is performing a pre-procedure anesthesiology assessment for another MD who is performing the LP and chemotherapy service. Is anyone aware of a billable CPT for this pre-procedure assessment on the same date as the LP and initial Chemo service?

The MD is documenting as if he is the anesthesiologist with ASA classifications, time frames and mallampati scores. He indicates his assessment is just prior to the anesthesia service but his documentation includes an eval and mgmt. exam.

Thank you.