EM Coding Alert

Question: One of our providers will decide that a patient has to have surgery, then have the patient come back just before the surgery to go over everything with the patient, especially if there is a gap of a couple of months between appointments. The provider wants to bill a level-4 office/outpatient evaluation and management (E/M) visit for the second visit, even though nothing has changed in the patient’s situation since the first encounter. Can we do this? Or is the second visit regarded as part of the global package for the surgery?

AAPC Forum Participant

Answer: If the payer is Medicare, or a payer following Medicare preoperative global surgery guidelines, after the provider makes the decision to perform surgery, any preoperative visits related to the surgery fall under the global surgery payment (www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf).

In your scenario, as nothing has changed since the provider made the decision for surgery in the first encounter, the payer will consider the second E/M visit part of the global package for the surgery. This would be especially true if, for example, the purpose of the second visit was to sign consent forms and discuss postoperative directions. As there has been no change in the provider’s medical decision making (MDM) since the first encounter, the MDM would be counted for that encounter, not the second.

Note this exception: If the patient’s situation changes between the first and second visits in your scenario, you might be able to make the case for billing another office/outpatient E/M.

For example, suppose the patient develops a serious medical condition in the interim, and the condition, while unrelated to the reason for the surgery, means the outcome of the considered surgery is now in doubt. The provider may then consider the surgery to be too high risk and postpone it, or the provider may consider alternative treatments for the initial condition.

In such a case, the provider performs additional MDM about the surgery, and you may bill for a second office/outpatient E/M based on that information. This may hold true even if the provider continues with the original decision to perform the surgery. But your documentation will need to reflect this new information and MDM.