Wiki chief complaint-I really really need

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cynthiabrown

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I really really need some help with this. I code for general surgeons who do bariatric surgeries. The patient comes in and doctor does initial visit and sends patient to do whatever they need to do before surgery........physch eval, cardiology clearance, etc. At this point in time, they schedule the surgery. A few weeks before the surgery date, they are bring ing the patient back to the office and calling it a pre op exam. they are even dictating pre op visit as the chief complaint. The office coder is putting a v72.38 pre op exam on as a diagnosos secondary to the obesty diagnosis. Thoughts???
 
chief compliant

what CPT code they are entering, do they have to reconcile these appointments, or have to enter anything for tracking purposes.????? That is my question.....
 
The procedure planned includes as a part of the procedure the pre op visit. Therefore I would not charge for the pre op encounter since that would be being paid twice.
 
I completely agree with Debra. CPT Assistant just had an article about this that stated if the decision has already been made for surgery and the patient is returning specifically for a pre-op visit or an H&P, then it is considered global to the major surgery and should not be billed.
 
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