Surgery Bundling--help!!!!

klash992

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For an orthopedic IP surgery, is the history and physical included in the surgery or can it be billed separtely?
 

klemkosky

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CPT Surgical Package Definition
The services provided by the physician to any patient by their very nature are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services "included" in a given CPT surgical code, the following services are always included in addition to the operation per se:

Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)

Immediate postoperative care, including dictating operative notes, talking with the family and other physicians
 

donsqueen

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Generally it would be included, however, if the admission was of an urgent/emergent nature, it may be billable.
 
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Was it the decision for surgery?

donsqueen writes: Generally it would be included, however, if the admission was of an urgent/emergent nature, it may be billable.

So if the first encounter with the patient for this problem is the admission, i.e. the decision for surgery, then it can be coded - don't forget the -57 modifier.

F Tessa Bartels, CPC, CPC-E/M
 
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