# Surgical Package and E/M



## dballard2004 (Mar 7, 2011)

The CPT Manual states the following regarding reporting an E/M and a surgical procedure:  

"Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure"

To translate this into simple terms, would I be correct if I said that this means that once the decision has been made to operate, any preoperative E/M service that occurs the day of the surgery or the day before the surgery is inclusive of the procedure?

Would this be a correct statement?  I am trying to educate my providers on the global surgical package.  I understand CMS has a different perspective on this.  Thanks.


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## btadlock1 (Mar 7, 2011)

dballard2004 said:


> The CPT Manual states the following regarding reporting an E/M and a surgical procedure:
> 
> "Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure"
> 
> ...



Not exactly - think surgical clearance exam - that's what they were referring to. An unrelated E/M the day before or day of the surgery is reportable - just don't forget to use a modifier when necessary to identify the significant, separately identifiable E/M service.


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## dballard2004 (Mar 7, 2011)

Thanks Brandi,

Just to clarify....once the decision to operate has been made, any *related* E/M that occurs on the day before the surgery or the day of the surgery is inclusive of the procedure.  

Am I on the right track now?


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## RebeccaWoodward* (Mar 7, 2011)

There is a CPT Assistant that addresses this...

Q:Are preoperative visits billable? If so, what code should be used and what is the time frame before surgery to submit this code?

A:If the decision for surgery occurs the day of or day before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical alone.* If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package.*


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## dballard2004 (Mar 7, 2011)

Thanks Rebecca,

Let me give you a scenario here.....let's say that a patient comes into the clinic to see the provider regarding a lesion.  After evaulation (E/M), the provider and the patient decide to remove the lesion, but the provider can't remove the lesion on this visit for whatever reason, so the patient is scheduled to return either the next day or a couple of days later for the lesion removal.  When the patient returns, the provider then performs a brief evlauation again checking the patient's medical history to make sure there will be no contridictions to the procedure and then also does a brief exam of the lesion to make sure there have been no changes to it since the last visit.

Since the decision to operate has already been made at the previous visit, am I correct that the evaulation described above would then be inclusive of the procedure?

What about if the patient goes into the hopsital for a scheduled surgery and the surgeon visits the patient the night before and reviews the lab results and performs a brief evaluation on the patient to make sure all is okay before the surgery and maybe answers some questions the patient may have regarding the proceure, since the surgery has already been scheduled, this "Preop" service would be inclusive, correct?

Sorry for all the questions here.


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## btadlock1 (Mar 7, 2011)

dballard2004 said:


> Thanks Rebecca,
> 
> Let me give you a scenario here.....let's say that a patient comes into the clinic to see the provider regarding a lesion.  After evaulation (E/M), the provider and the patient decide to remove the lesion, but the provider can't remove the lesion on this visit for whatever reason, so the patient is scheduled to return either the next day or a couple of days later for the lesion removal.  When the patient returns, the provider then performs a brief evlauation again checking the patient's medical history to make sure there will be no contridictions to the procedure and then also does a brief exam of the lesion to make sure there have been no changes to it since the last visit.
> 
> ...



What you're describing is included in the global package - any E/M service that would be considered a pre-op clearance exam/discussion/etc. after the decision for surgery is bundled into the surgery.


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## dballard2004 (Mar 7, 2011)

Thanks Brandi,

I think I get it now.  Any E/M that is pre-operative clearance is part of the global if performed the day before or the day of the surgery once the decision for the surgery has been made.

If the E/M results in the decision to perform the surgery and it is done the day before of the day of a major surgery, you report modifier 57.

If the E/M results in the decision to do a minor surgery and the E/M is significant and separately identifiable and performed on the same day as the procedure, you report modifier 25.

Correct?

But....what happens if the an E/M service is performed on the day of the surgery or the day before the surgery that is related to the surgery (once the decision has been made to operate), but is not for pre-operative clearance?  Is this part of the global, or is the "assumption" made that any E/M related to the surgery following the above would be considered "preoperative clearance?"


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## btadlock1 (Mar 7, 2011)

Like, say, an unforseen acute complication? It's billable, as long as the doctor documents the need for the separate E/M. If it happens to be the day of the surgery, you'd need a 25 modifier, but I'm not sure about the day before. I don't believe that a modifier is required, but I'm not sure how a claim in that circumstance would be processed, so I don't want to tell you something that might be wrong. My gut says no modifier, though.


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## dballard2004 (Mar 8, 2011)

I think I get it now!  Thanks so much for your help!


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