Wiki question about decision for surgery

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coder25

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Hello all,

We have a patient in the hospital right now, which we saw for the first time for gallstone pancreatitis. During the course of her hospitalization, the doctor's plan stated that in 4-6 weeks, he plans on performing a lap chole. The patient was still in the hospital for six days after this and there are notes written.

If the decision for surgery is already made, can I still bill out the subsequent hospital visits, especially if they keep talking about the lap chole???

Also, the patient will be returning to the office to discuss the lap chole, will that E/M be billable???

I am thinking not, but needed other opinions.

Thanks so much!
 
The surgery was not done during this inpatient stay, there is no global period at this point so as long as the visits were medically necessary they should be billed.

As far as the out patient visit prior to the surgery, unless something changes and they decide not to do surgery I probably would not bill that one.

Laura, CPC, CEMC
 
Billable

The hospital visits are all billable.

The office visit "to discuss the lap chole" ... if this is to (re)evaluate and make a final decision for surgery I would bill it out.

BUT if this is just to finalize the surgery scheduling and get consent forms and H&P filled out I would not code it (even if it's outside the official global period).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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