decisionhealth Newsletters, Coder Pink Sheets - 2010 Issue 9 (September)
Understanding E/M: Surprise! You might be able to bill for that pre-op exam
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Article Overview
This article explains the general treatment of pre-operative anesthesia evaluations within the anesthesia care package and discusses limited circumstances in which separate evaluation and management reporting may be considered. It is aimed at anesthesiologists, CRNAs, coders, and billing staff who need to understand documentation expectations, payer scrutiny, and references to CMS-related guidance.
Why This Topic Matters
Pre-operative evaluations are commonly part of anesthesia services, but specific scenarios can affect whether separate E/M billing is considered. Understanding the article helps practices recognize when documentation, medical necessity, and payer rules become especially important.
Article Sections
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General rule for pre-operative evaluations
Introduces the usual treatment of the pre-operative examination within anesthesia services and summarizes the broad purpose of the evaluation.
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Surprise #1 - The surgery is cancelled
Discusses one exception scenario involving a cancelled procedure, along with related documentation and payer guidance considerations.
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Surprise #2 - The patient isn't ready
Covers another exception scenario involving additional assessment of a patient’s readiness for anesthesia and the broader type of work-up that may be involved.
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Warning and official resources
Summarizes the article’s caution about payer review and points readers to the cited CMS-related reference material.
What You Will Learn
- How pre-operative anesthesia evaluations are generally treated within the anesthesia package
- Which broad circumstances may lead to separate E/M consideration
- What documentation themes are emphasized for supporting the service
- Why payer review and audit risk are highlighted
- Where the article points readers for official guidance
Who Should Read This
- Anesthesiologists
- Certified Registered Nurse Anesthetists (CRNAs)
- Medical coders
- Billing staff
- Revenue cycle personnel
Codes Discussed
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