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Preoperative consult and new problem

  1. #1
    Default Preoperative consult and new problem
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    I am coding a preoperative consultation (which does meet the reason, request and reply criteria) but the physician states that the patient is in for 2 reasons, the consultation and a new problem of anxiety which she dictates a seperate note on. My question is, is it appropriate to code a consultation E/M with a 25 modifier for the preop and an office call E/M for the anxiety...or would the consult code cover the whole visit?

  2. #2
    Milwaukee WI
    Default Consult
    I'm guessing that the anxiety is realted to the upcoming surgery. Your consult will cover both problems, but you would take your new problem into account when determining MDM (problem points).

    F Tessa Bartels, CPC, CEMC

  3. #3
    Thank you so much for your help!

  4. #4
    The anxiety is not related to the surgery...does this change your advice on this one? I think the consult is all I should be coding, but I keep second guessing myself.

  5. #5
    Greeley, Colorado
    I would say that you have to incorporate the new problem into the pre-op clearance consult. Your additional E/m -25 will just be denied.
    Lisa Bledsoe, CPC, CPMA

  6. #6
    I agree, this should only be the consult.

    The consult code itself is a problem visit. The only time I am aware of having 2 E/M services during the same visit is when one is preventive and the other is a problem. So you would just use the info regarding the anxiety and add that to the pre-op reasons and level it all together as a consult.

    Of course there is also the scenario of workers comp visits in addition to private insurance visit but I don't think that is your situation in this case.

    Just my opinion,

    Laura, CPC, CEMC

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