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Pre-Op and Complaint

  1. #1
    Overland Park, KS
    Default Pre-Op and Complaint
    Medical Coding Books
    If a patient presented to the office for a pre-operative clearance for bunion surgery and the provider addressed an additional complaint of a migraine during the encounter, would this be considered part of the consultation, or would you report an office/outpatient E/M code (99201-99215) instead? Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  2. #2
    Ellenville, New York
    Default Opinion for digestion
    Given this information, I would make the treatment of the migraine part of the consultation. The pre-op consult is the reason for the visit. If the visit was for the migraine as the CC, then I would use the office visit codes.

  3. #3
    Overland Park, KS
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

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