Neurosurgery Coding Alert

Question: Can we charge for a preoperative visit when the surgeon performs a history and physical (H&P) for surgical clearance prior to surgery? If so, what code do we use?

Maine Subscriber

Answer: Only if-

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

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

-you may report an appropriate-level established patient E/M visit for a pre-surgical H&P.

These circumstances would occur if the patient developed a new problem or experiences another significant change of status in the days prior to surgery. In such a 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 concerns 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).

A routine H&P on the day of, or day before, a major surgery, definitely falls within the global period.