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E/M codinf

  1. #1
    Anaheim, CA
    Smile E/M codinf
    Medical Coding Books
    Office visit vs. Consultation

    If a patient comes for a preop evaluation visit to the PCP ( not the Surgeon )before the surgery takes place, should it be a office visit with the preop diag. or a consult to the PCP.

    I would really appreciate the quick response.


  2. #2
    Greeley, Colorado
    IF documentation meets all of the requirements for a Consultation (Request/Render/Report) then you should code a consultation. Use the appropriate V code for the primary dx, the reason for the surgery as the second, and any other conditions addressed as subsequent dx.

  3. Default
    Is the PCP sending the patient to the surgeon for the surgery? If the PCP is the physician that requested the surgeon's advice/opinion about a situation, and then in turn the surgeon decides a surgery is needed, I would think it would be an office visit. I don't see the medical necessity in a consult.

    On the reverse, if another physician sent the patient to the surgeon, and the surgeon is requesting preop eval from the PCP, if all qualifications of a consult are met, it may be appropriate.

    Any other opinions?

  4. Default
    I agree that if the PCP sent the patient to the surgeon, then the service should be billed as an office visit.

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