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Office visit question

  1. Default Office visit question
    Medical Coding Books
    My office manager & I disagree about this. If a patient was previously seen AND the decision has been made for surgery, ex: H & P done, and say, the surgery was canceled, can you charge another small office visit charge if the patient comes in to discuss the upcoming surgery?
    I need something in writing to show her! LOL!


  2. #2
    North Carolina
    Do you have access to CPT Assistant? If so, there is a Q/A on this very question (May 2009)....

    "If the decision for surgery occurs the day of or day before the major procedure then this visit is separately reportable. Modifier 57 is appended to the E/M code. If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package."

    If there was a change in the patient's health status (i.e-exacerbation of a comorbidity), it's possible an E/M is warranted; however, the documentation needs to prove medical necessity.
    Last edited by RebeccaWoodward*; 01-24-2011 at 10:29 AM.
    Rebecca CPC, CPMA, CEMC

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