Orthopedic Coding Alert

Knowing how to navigate and select all of the codes necessary to report a preoperative encounter takes a lot of knowledge. Boost your evaluation and management (E/M) service coding confidence, and remember that some ICD-10 knowledge is crucial, too.

Read more about the ins and outs of reporting a pre-op evaluation.

Focus on the Decision for Surgery

One common source of confusion has to do with separate E/M billing. For example, let’s say the surgeon sees a patient and schedules an operation based on that visit. When the patient comes back the day before the surgery for a pre-op evaluation, can you bill another E/M even if nothing has changed from that first encounter?

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.

So, under Medicare rules, once the provider makes the decision for surgery, you should not separately bill any preoperative visits related only to the surgery. In other words, the prescreening visits don’t usually present new information that warrant the need for an E/M service.

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.

Modifier alert: Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) when there is a separately billable E/M. Documentation must clearly support the separate service. “We need a robust paragraph of evaluation and management,” says Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

Learn more: You can read about global surgery guidelines at www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf.