decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Preoperative Exams / Fulfill all EM Documentation Requirements
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Article Overview
This article discusses preoperative examinations in the context of evaluation and management documentation requirements, claim diagnosis ordering, and the circumstances under which a separate exam may be considered. It is intended for coders, billers, and clinicians who need to understand how preoperative exams relate to surgical and anesthesia services, including common documentation and billing considerations.
Why This Topic Matters
Preoperative exams can affect whether an encounter is billed separately or treated as part of a surgical or anesthesia package. Understanding the article helps coding and billing staff recognize when documentation and diagnosis sequencing are especially important.
What You Will Learn
- When a preoperative evaluation may be considered separately billable
- What documentation expectations apply to an evaluation and management visit
- How diagnosis sequencing is discussed for preoperative exam claims
- Which general perioperative circumstances are addressed in the article
Who Should Read This
- Medical coders
- Medical billers
- Physicians
- Anesthesia professionals
- Compliance staff
Code Ranges Discussed
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