# Billing H&P before scheduled surgery



## tlm5506 (Jun 30, 2014)

Hello.
Current debate in our office is whether an office visit can be billed prior to a scheduled surgery. This visit would be for the H&P for the surgery. The visit was done a week before the scheduled surgery. I am reading several different opinions on this. I read that the global period starts just 1 day before the surgery (this would be a major surgery), so an H&P obviously would not be billable the day before the surgery. However, as stated previously, this visit was done a week before the surgery. Is this a billable visit? If not, I need to know where that information is coming from as far as not being able to bill for the visit. 
Thanks for your help.


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## OCD_coder (Jun 30, 2014)

The H&P is not a billable service when the decision for surgery is made, in your case a week prior to the actual surgery.  It's the % portion called "Preoperative" of the global package.  There is no medical necessity to support reporting this service.

*Per CPT Assistant Feb 2009 Q and A Section, Page 22 and May 2009 page 9, 10 Category Coding Clarification Preoperative visits, guidelines.*

If the decision for surgery occurs the day of or day before the major procedure and includes the preoperative E&M services, then this visit is separately reportable.  Modifier 57, Decision for Sugery, is appended to the E&M code to indicate this is the decision-making service, *not the history and physicial (H and P) 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 and 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.*

*Example:*
The surgeon sees the patient on March 1 andmakes a decision for surgery.  Surgery is scheduled for April 1.  The patient returns to the office on March 27 for the H and P, consent signing, and to ask and clarify additional questions.  This visit on March 27 is not billable, as it is the preoperative H and P visit and is included in the surgical package.


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## tlm5506 (Jul 1, 2014)

Thanks.


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## sparkles1077 (Jul 1, 2014)

So what if the person performing the procedure is an oral surgeon and he/she is performing this procedure at a local hospital.  The local hospital requires an H and P for every patient undergoing anesthesia in the hospital for a procedure.  The oral surgeon has an internist perform this H and P several days before the procedure.  Would this be considered bundled as well?  It is challenging because the provider performing the H and P is not the oral surgeon.  The oral surgeon is not qualified to perform this H and P as they are dental.  These patients do have multiple comorbidities, which is why the oral surgeons have to have them in the hospital for the dental procedures.  I am uncertain of what the dental procedures are.

Thank you for any advice on this scenariol


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## OCD_coder (Jul 2, 2014)

Sparkles,

Here is an article that may help guide you to understanding how to approach your situation.  This scenario can be a company policy situation, my company requires the surgeon to perform the preop or identify clearly why the hospitalist needs to manage the comorbidity.  The hospitalist then, focuses the H&P on the comorbidity and not the surgical problem.  This supports medical necessity for the service to be billed.

*Article:*
Q: My question has to do with billing for perioperative care. Say a patient is having surgery and the hospitalist goes to the floor or to the outpatient surgery unit to perform either preop or postop care for the surgeon. Can we bill for that service, or is it included in the surgical package?

A: If the hospitalist is asked to give an opinion on whether a patient can undergo surgery, bill either an inpatient or outpatient consultation code, depending on the setting. A consultation would not be considered part of the global package.

According to my source at Medicare: If a consult is not being requested, a transfer of care has not occurred, and a preop service is done within the global period by another physician who is not part of the group doing the surgery, you would bill for the service as a hospital visit.

*If a transfer of care has taken place, however, a routine preop exam and/or postop care could be considered part of the global period.* In this situation, you would have to carve out billing for preop or postop management services by using either the preoperative modifier (-56) or the postoperative-management-only modifier (-55). (Keep in mind that Medicare does not recognize modifier -56, so just bill the service without the modifier for Medicare patients.) Use the modifier in conjunction with the surgery CPT code being billed by the surgeon.

Surgeons aren?t fond of this option because it divvies up the global payment between the hospitalist and the surgeon. The surgeon should also use modifier(s)?such as the surgical care only modifier, -54?to represent that portion of the global period he or she performed.

More information on Medicare?s global surgery guidelines is online. The pertinent section is 100-4, chapter 12, section 40.

http://www.todayshospitalist.com/index.php?b=articles_read&cnt=746


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## sparkles1077 (Jul 2, 2014)

Thank you OCD!!!!  It does seem like there should be a way to bill, considering oral surgeons don't typically perform H and Ps.


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## losborn (Jul 3, 2014)

*What if the hospital bills the H&P?*

Scenario:  surgery is being performed at ABC hospital outpatient by Dr. X.  The hospital bills for an H&P performened by a NP.  
Also performed are the routine blood labs and EKG.  There is nothing specific in the record requesting that a cardiologist (or anyone else) consult on the case.  

Can the hospital bill for these services?  Or are they, too, considered part of the surgical package as the procedure is scheduled to be performed at hospital ABC by Dr. X?

Thanks


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