DecisionHealth, DecisionHealth - 2023 Issue 4 (April)

Q&A: TKA was six months after decision for surgery but pre-op H&P is still bundled

Question: The patient has osteoarthritis of the left knee. The surgeon and physician assistant (PA) discuss the options with the patient and the patient makes the decision to have a total knee arthroplasty. The patient agrees to the surgery and the surgery is ordered on the day of the appointment, 4/11/22. The patient then calls and schedules a pre-op appointment for 11/30/22. On this visit, the PA does a full exam, orders X-rays and reviews them. The surgery paperwork is completed and the PA goes over all the pre-op and post-op instructions. The patient signs the consent forms. The patient has the surgery the following week and they are not seen again prior to surgery. Is it acceptable to charge an E/M code for this pre-op visit since the patient had to be re-evaluated or will this visit still be bundled into the global surgery package?

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