E/M Coding Alert - 2010 Issue 8
Reader Questions: Include H&P With Surgical Code, Skip Separate Billing
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Article Overview
This short coding guidance article addresses a common preoperative billing question for surgical cases. It explains the general relationship between a surgeon-performed history and physical, the surgical global package, and when a separate evaluation and management service may be considered. The article is relevant to coders, billers, and surgical practices looking for high-level clarification on office visits tied to operative care.
Why This Topic Matters
Preoperative encounters are a frequent source of billing confusion, and incorrect separation of related services can affect claim accuracy. This article helps readers understand the general scope of when a pre-surgical office encounter is treated as part of the surgical service and when an evaluation and management visit may be associated with a surgery decision.
What You Will Learn
- How preoperative office encounters are discussed in relation to surgical billing
- How the surgical global package is addressed in a pre-op context
- How decision-for-surgery timing relates to evaluation and management reporting at a high level
- What kinds of encounters are commonly treated as part of the main procedure versus separately reported services
Who Should Read This
- Medical coders
- Billing staff
- Surgery practice administrators
- Physician office staff
- Revenue cycle professionals
Codes Discussed
Modifiers Discussed
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