General Surgery Coding Alert

Question: When a surgeon sees a patient and schedules a surgery, can we bill another E/M visit when the patient comes back the day before surgery for a pre-op check in, even though nothing has changed in the patient’s situation since the first encounter?

Mississippi Subscriber

Answer: The answer may depend on the payer. For payers such as Medicare that have “global surgery” guidelines, you must bundle certain services before and after the surgery based on the rules for the appropriate global period.

Under Medicare rules, once the provider makes the decision for surgery, you should not separately bill any preoperative visits related only to the surgery.

Exception: If the patient’s situation changes between the first and second visits before surgery, you might be able to make the case for billing another office/outpatient E/M.

For instance, if the patient develops a serious medical condition that is unrelated to the reason for the surgery, but could impact the outcome, the surgeon may perform additional services that increase the level of medical decision making (MDM) and, if properly documented, could allow you to bill a separate E/M visit.

Resource: You can read about global surgery guidelines at www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/ globallsurgery-icn907166.pdf.