I hate to be less than definitive, but much depends on the documentation of a particular case.
Is fracture care being provided at that first visit? Or is there an absolute certainty that surgery will be needed, but it can't be scheduled for a few days or a week?
If fracture care is provided at the first visit you'd bill the fracture care (closed treatment) and put a -57 modifier on the new patient visit (decision for surgery). If NO fracture care is provided you don't need the modifier.
There is NO charge for the pre-op visit ... even if it's done more than 48 hours before the actual surgery. There is no medical necessity for this additional office visit; the decision for surgery was performed at the first visit.
Date of surgery ... you code the open fracture treatment - IF there was closed treatment performed on 1st office visit, you add -58 modifier to the surgery. NO E/M code.
I think you probably have a Compliance office that should be able to help you by looking at the actual documentation.
F Tessa Bartels, CPC, CPC-E/M
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