General Surgery Coding Alert

Question: Can we charge for a preoperative visit when the surgeon performs a history and physical (H&P) for surgical clearance?

Maine Subscriber

Answer: You may report an established patient E/M visit for a pre-surgical H&P only if:

- the service occurs more than 24 hours prior to the surgery, and

-the service satisfies your payer's medical-necessity requirements

These circumstances would occur, most frequently, if the patient develops a new problem or experiences another significant change of status in the days prior to surgery. In such as case, you-d want to be sure to link the appropriate diagnosis or signs and symptoms to any E/M service code you report. This will help establish medical necessity for the visit.

Note: For an H&P (or admission) on the same day as an unscheduled or emergency procedure, with the surgeon making the decision for surgery during the visit, you would report an appropriate E/M service code with modifier 57 (Decision for surgery) appended.

Learn more: For complete information on how and when to apply modifier 57, see "Modifier 25 Isn't Always the Answer for Same-day E/M," General Surgery Coding Alert, vol. 10, no. 11, pages 83-85.

Often, however, the hospital or other facility will require a pre-surgery H&P as a standard procedure, without any signs and symptoms or other specific concern to trigger the visit. In such cases, you should not report a separate E/M service. Instead, you would consider the H&P as incidental to scheduled procedure.

For example, the surgeon makes a decision to perform surgery on Dec. 1, schedules the procedure for Dec. 10 and brings the patient back on Dec. 7 for an H&P.

The H&P in this case is not billable, even though it does not fall within the global period of the procedure (which begins prior to surgery for procedures with a 90-day global), because carriers likely will not consider the pre-surgical H&P medically necessary.

Dx. tip: For a routine pre-surgical H&P the surgeon performs on a visit not involving a decision for surgery, the correct diagnosis is V72.83 (Other specified preoperative examination).

Note that if a routine H&P service falls on the day before, or the day of, a major surgery, that service definitely falls within the procedure's global period.