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Thread: Surgery Bundling--help!!!!

  1. #1
    Join Date
    Apr 2007

    Default Surgery Bundling--help!!!!

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

  2. #2
    Join Date
    Apr 2007


    this is included in the surgery you can not bill seperately

  3. #3
    Join Date
    Apr 2007


    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

  4. #4


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

  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default 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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