tci General Surgery Coding Alert - 2008 Issue 12

You Be the Coder: When Can You Report Presurgical H&P?

Question: Can we charge for a preoperative visit when the surgeon performs a history and physical (H&P) for surgical clearance? If so, what code do we use? Maine Subscriber Answer: You may report an established patient E/M visit for a pre-surgical H&P only if: - the service occurs more than 24 hours prior to the surgery, and -the service satisfies your payer's medical-necessity requirements These circumstances would occur, most frequently, if the patient develops a new problem or experiences another significant change of status in the days prior to surgery. In such as case, you-d want to...

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