Wiki Pre op visit posting

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cwilson3333

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I am told I should be billing a Level 5 for pre-op scheduling of surgery?

Can I get some feedback on this scenario from other charge posters?

Thank you
CW
 
1) There is never a set level for any specific E/M service. Coding is done based on the medical necessity and documentation.
2) Was the decision for surgery already made and the patient is returning to the surgeon for a pre-op appointment? If so, that is part of the global package. If not, then as per above, coding is based on medical necessity and documentation.
 
If patient is [1] being seen either as a new patient, and surgery is scheduled on this visit, or [2] is just returning for follow up and treatment has not been successful, and surgery is now scheduled at the return appointment,
would either of these scenarios meet a level 5 coding. Neither of these appointments are scheduled as pre-op appointments, just the result of the examination.
 
I don't think you're getting it. There are no details in your post to determine visit level. You cannot say that a particular type of visit is always a certain level.
 
This is simply not enough information to determine an E/M level. Outpatient E/M 2021 is based on MDM, which has 3 components:
Number & Complexity of Problems Addressed
Amount/Complexity of Data Reviewed and Analyzed
Risk
Stating the patient is being scheduled for surgery only partially tells 1 of the 3 components (risk).
It might be a level 5. It might also be a level 3. Or a level 4.
 
csperoni said:
This is simply not enough information to determine an E/M level. Outpatient E/M 2021 is based on MDM, which has 3 components:
Number & Complexity of Problems Addressed
Amount/Complexity of Data Reviewed and Analyzed
Risk
Stating the patient is being scheduled for surgery only partially tells 1 of the 3 components (risk).
It might be a level 5. It might also be a level 3. Or a level 4.
Click to expand...
Thank you for your response. I realize I hadn't posted enough info for anyone to review. I posted the question too quickly after I was told I needed to start billing level 5 on pre op visits. 😏
Will refer the doctors also to look back over this link
 
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