# Preop Exams



## cmacpc (Oct 17, 2011)

I am coding for a large group and deal with a large volume of Trauma as we are a level 3 trauma ctr.  When I review the preops I may get them with ??? marks on the forms or blank and just a signtature.  I have asked for them to state why they are unable to complete the form, the other day the anesthesiologist told me it was imposible as the patient was intubated, and this was on the anesthesia record, I explained that these are two different records and both need to be completed.  I got the preop back & he wrote on the form " impossible pt intubated unable to explain!" Does any one else have these problems, does any one else review pre and post ops?? Any suggestions??

TIA


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## kpride (Oct 17, 2011)

Just curious, what is the purpose of the form?  Is it for billing?  Compliance?  If due to the patient's condition the anesthesiologist did not perform a pre-op exam, there would be nothing to document; therefore, nothing to code/bill.


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## kpride (Oct 17, 2011)

Just curious, what is the purpose of the form?  Is it for billing?  Compliance?  If due to the patient's condition the anesthesiologist did not perform a pre-op exam, there would be nothing to document; therefore, nothing to code/bill.


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## ANDREAHSANCHEZ (Oct 17, 2011)

well it is a little confusing as to where you are directing your question and my billing cercumstaces are a little different as I am billing for urgent cares. Are you trying to code or just get them to fill out the forms, or sorry I am a little unclear here please explain.


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## cmacpc (Oct 17, 2011)

*pre ops*

I am doing this as part of compliance as well as part of our coding.  The ASA states that every patient record should include Pre eval/pre op, and they list several items that must be covered on that form such as px status, medica hx, ASA hx, NPO status, etc., This is the form I am referring to.  I do not bill separtely for it.  I am asking if anyone has problems getting there physicians to complete them, I believe they have 48 hrs to complete them not sure on the time frame????


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