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Thread: E/M codinf

  1. #1
    Join Date
    Apr 2007
    Anaheim, CA

    Smile E/M codinf

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    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. #3


    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. #4


    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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