# Pre-op outside global surgical package



## Stefanie (Sep 23, 2010)

Once the decision for surgery has been made, can the surgeon/OB/Gyn bill for a "pre-op" one week prior to the major surgery?  I understand that the surgical package includes an E/M the day of or the day before the major surgery unless a decision for surgery is made during the visit, BUT, what about a major surgery that was decided on October 1, the surgery is scheduled for November 15, the patient sees the surgeon on November 10th to go over consent signing, preparation for the surgery etc., is the November 10th visit included in the surgical package (no according to the guidelines)? The provider/surgeon believes it's billable because the visit is before the surgical package begins.  I believe, because it's a related service to the major surgery and it's a service that could potentially be done the day before the surgery, it's included in the surgical package.

I have read Medicare's Surgery Manual, it supports both our beliefs.  I can give my opinion but I really need some documented back up.  

Does anyone have any suggestions, thoughts, opinions?

Thanks  Stefanie


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## Carrie880 (Sep 24, 2010)

From Medicare’s Global Payment Policy
For procedures subject to Medicare’s global payment policy, payment includes: 
Preoperative visits related to the surgery, includes pre-op visits after the decision to perform surgery is made.

NOTE* The same rule applies if it is decided during an E&M that patient will return to the office for a minor procedure (ex, trigger point injection, joint injection) if the patient returns for the minor procedure and there are no other new or unrelated problems an E&M service should not be billed, only the minor procedure. 

The initial E/M where the decision for surgery is made is not bundled into preoperative visits but will requrie 57 modifier if surgery is scheduled within 24 hours.


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## bonzaibex (Sep 24, 2010)

Here are 3 paragraphs from a Medical Coding Wire newsletter article dated 02/2007:

"An H/P done the day before or the day of surgery is included in the global," says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician education specialist for the department of surgery at UPMC Presbyterian-Shadyside in Pittsburgh. But you'll have to carefully examine the specifics of any visit two days or more before the surgery.

Suppose the physician saw the patient two months ago and at that visit decided to perform the surgery. Now the patient (who is in good general health) returns to your office for an H/P because the hospital requires it before the surgery. "If the H/P is only a hospital requirement and not medically necessary, then no matter when the surgeon performs it, it isn't billable," Hvizdash says.

"If, however, the patient gets all the proper clearances, but the surgeon saw the patient when she was dealing with an active issue, the H/P might be necessary," Hvizdash says. "The surgeon needs to make certain that the patient is healthy enough to withstand surgery. If this is the case, the H/P done more than a day before surgery is billable."

--Becky, CPC


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## ALEW (Sep 24, 2010)

Do you have access to CPT Assistant May 2009 Vol. 19 Issue 5?  Here is what it states.......


_Coding Clarification

In the February 2009 Q&A section, page 22, a question was asked regarding whether preoperative visits are billable. It was noted that the answer provided was incomplete and could be misinterpreted. The following clarification addresses the question in greater detail. The Q&A should read as follows:

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

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


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## nbluvette (Sep 24, 2010)

This is the key----------- the intent of the visit is related to the surgical problem or the preoperative H&P - these become global

If there was a separate medical problem unrelated to the surgical problem an E/M could be billed.


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## Stefanie (Sep 29, 2010)

Thank you all for your abundance of resources.  They were all exactly what I needed to support the H&P NC one week before surgery.  Thank you all again for your prompt responses.


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