Wiki Preoperative visit for elective repeat C-sect

[BPalumbo1129]

Good morning,

A 39 week gestational age OB patient who elected to have a repeat C-sect due to suspected macrosomia presents to our OBGYN office for a preoperative exam for the C-sect. The C-section is scheduled to be done in 2 days. The patient's previous C-sect delivery was due to polyhydramnios and macrosomia. The provider does the basic preoperative exam, discussed the risks of the repeat C-sect procedure in full with patient signing the consent, and reviews the patients preferences/birth plan to delivery. The provider documents she spent 30+ minutes visit with >50% spent in discussion and counseling. Is it possible to bill an E/M visit code for a preoperative exam for the elective repeat C-section separate from the global maternity charge? I appreciate your feedback in advance..

Thank you,
Bernadette Palumbo, CPC

 

[nielynco]

Good morning,

A 39 week gestational age OB patient who elected to have a repeat C-sect due to suspected macrosomia presents to our OBGYN office for a preoperative exam for the C-sect. The C-section is scheduled to be done in 2 days. The patient's previous C-sect delivery was due to polyhydramnios and macrosomia. The provider does the basic preoperative exam, discussed the risks of the repeat C-sect procedure in full with patient signing the consent, and reviews the patients preferences/birth plan to delivery. The provider documents she spent 30+ minutes visit with >50% spent in discussion and counseling. Is it possible to bill an E/M visit code for a preoperative exam for the elective repeat C-section separate from the global maternity charge? I appreciate your feedback in advance..

Thank you,
Bernadette Palumbo, CPC

From your question it appears that the patient had already decided to have the cesearan prior to the preop visit. In that case, the preop is is included in the work required to do the cesarean and as such not separately billable (the code for cesarean includes physician pre-operative time of 232 minutes per the RVRVS database). You provider may use this information as part of his/her required admit H&P as well (which is also included in all delivery codes).

 

[BPalumbo1129]

Thank you!