Wiki H&P for tubal ligation

[TLOVE]

Provider used Z01818 and Z302 on his H&P for a tubal ligation. Z302 can only be used on the procedure. What code do you use for the reason for the surgery?

 

[dja214]

The provider is correct with the ICD-10 codes. Why are you billing an H&P? This should be an OPPS procedure and pre-planned therefore H&P is included with the procedure. The provider simply has to update the H&P from a visit within the past 3 days. Refer to ICD-10-CM guidelines Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services.

If the patient is being admitted due to complication, then you code the complication.

Hope this helps!
Regards,
Deanna

 

[TLOVE]

The surgeon sent an order to the patient's family practice provider to perform a history and physical to see that patient is fit for surgery. The family practice provider used the Z01818 and Z302 on his clinic note. The surgeon will review that H&P that was done by family practice provider on the day of surgery and not bill an H&P as it is included in the procedure as you stated above.