Wiki Preoperative visit vs. E/M

[ahwhitten@msn.com]

Patient is referred to general surgeon for cholecystectomy. Studies were completed prior to the referral. Patient sees general surgeon as a new patient. Physician agrees that cholecystectomy is needed after examining the patient. Discussion ensues with risks and benefits discussed as well as informed consent obtained. Surgery is scheduled for several days or weeks out. Is this a billable service or is this a preoperative exam that is not billable and at what point does this become a preoperative exam?

Thank you for any help you might can give me on this topic.

 

[Chelle-Lynn]

That would be a billable service as the decision to perform the surgery was made at that time. Medicare has some good training resources on helping providers to understand when a service is pre-operative vs. decision for surgery in their Global Billing Materials.

Global billing does includes pre-operative visits to the surgeon, but only after the initial visit during which the surgeon determines that surgical intervention is the most appropriate care option for the patient’s condition.