Reader Question: Presurgical H&P

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Note:  The following article synopsis was NOT provided by AAPC. It was created by Find-A-Code/innoviHealth.

Article Overview

This reader Q&A addresses billing and documentation issues related to presurgical history and physical services performed before an operation. It explains the broad distinction between services bundled into a surgical global package and visits that may be separately reportable based on timing and medical necessity, with references to common E/M reporting concepts and Medicare-related guidance. The article is useful for coders, billers, and surgical practice staff who handle preoperative workflow and claim reporting.

Why This Topic Matters

Preoperative evaluation is a common source of confusion in surgical coding because similar-looking visits may be bundled, separately billable, or subject to different reporting conventions depending on the circumstance. Understanding the article helps reduce improper billing risk and supports more accurate claim submission for surgical practices.

Article Sections

  1. Question

    The reader asks about reporting a presurgical history and physical performed before surgery and which code may apply.

  2. Answer

    The response discusses the general distinction between services included with surgery and visits that may be separately reported, along with timing and coverage considerations. It also references established patient E/M reporting and modifier use in certain circumstances.

  3. Example and global period discussion

    An example scenario is used to illustrate timing relative to surgery and how the global package affects reporting. The section also notes the diagnostic labeling associated with a separate preoperative examination visit.

What You Will Learn

  • How presurgical history and physical services are generally viewed in relation to surgical billing
  • When a preoperative evaluation may be considered part of the surgical package versus separately reported
  • How timing and medical necessity affect preoperative visit reporting
  • How common E/M concepts relate to presurgical clearance workflows

Who Should Read This

  • Medical coders
  • Billing staff
  • Surgical practice administrators
  • Physician offices
  • Compliance staff

Codes Discussed

Code Ranges Discussed

Modifiers Discussed


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