Make sure you got the 3 R's covered Request from the other provider (surgeon?), a written Response from your doctor (opinion) & the Return of the patient to the requesting physician. Depending on the type of pre-op exam done (cardio/pulm), the pre-op code (V72.x) is always the primary code, then you need to code the reason the pt is having the surgery & then code all the risk factor the pt has, like HTN, DM, etc...
Last (but def not least), assign the E&M code, based on the pt status. I'm guessing he's an est. patient? We used to utilize the consultation codes, but this has changed (deleted), now it's either a new/est pt visit (99201-99214).
Hope this helps
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