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Pre-op E/M Question

  1. #1
    Default Pre-op E/M Question
    Medical Coding Books
    My physician saw a patient on 12/3/2010 for a pre-op visit (99204) for a screening colonoscopy
    (V76.51). My billing supervisor and I have been going back and forth with an insurance company that is refusing to pay for the office visit (the colonoscopy wasn't done until 1/14/2011). Recently they (insurance company) sent a letter stating "American Medical Association guidelines state that the E/M enounter should be included in the surgical package.

    Along with the letter they enclosed a copy of the CPT guidelines (page 52 under CPT Surgical Package Definition) "Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure."

    By the dates of service provided above, we are obviously more than 72 hours prior to the date of service. The provider is not a participating provider, and my supervisor and I both believe that this ovfice visit is payable by the insurance company. He was a new patient to the Dr. I am in need of some help from coders that have more experience than I do. I have never had this problem with an insurance company in three years of working in the field.


  2. #2
    Columbia, MO
    if the decision to perform the screening colonoscopy had already been made even if a different physician made the decision and set it up thru your office, you cannot charge again for this decision that is why the preop is included.

    Debra A. Mitchell, MSPH, CPC-H

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