General Surgery Coding Alert

Question: I have a pre-op H&P that my surgeon performed in the office on the day prior to the patient's surgery, but dictated to the hospital. This was not the date that the physician made the decision for surgery. Can I bill a separate E/M code for the office visit?

Florida Subscriber

Answer: No, you cannot bill a separate E/M service in this case. Your question clearly indicates that the purpose of the office visit was to perform the pre-surgery history and physical (H&P). Any H&P service your surgeon performs prior to a surgical procedure -- either on the day of surgery or even the day before -- is included in your charge for the surgical procedure. The H&P is included in the global of the main procedure.

Had the decision for surgery been made at that visit, you might have been able to bill an E/M service, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), with modifier 57 (Decision for surgery) appended. In this case, however, the office visit is not a separately billable service because you state the decision for surgery was made during another encounter.