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Thread: E/M subsequent to decision for surgery

  1. #1

    Default E/M subsequent to decision for surgery

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    If a physician is called to the ER to do a specific procedure, is the E/M a separately billable service? Here's what I was given-A patient was being prepared to be transported but it was decided he needed to be intubated first. My provider was called in and did a brief history, exp. pf exam and then did the intubation. His note does reflect the fact that he was requested to do the intubation. Would his note be considered a separately identifiable visit or would it be considered an H&P since the decision for the procedure was already made, hence the call for his service?
    Sue Vermette, CPC

  2. #2
    Join Date
    Apr 2007
    Kansas City, MO


    In the scenario you give, I would not bill the e/m. As you say, the decision to do it was already made. Any eval he did is built in to the procedure.

    Medicare's global surgery package guidelines are a good resource in writing for this. They explain that every procedure has an e/m component worked into it. Unless there was a complete evaluation and a clear decision made to operate, the e/m shouldn't be billed separately.

  3. #3


    Thanks for your response. That's the way I was leaning too...
    Sue Vermette, CPC

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