Health Information Management

Q&A: Charging for E/M services provided during a visit for preoperative clearance

JustCoding News: Inpatient, October 14, 2009

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QUESTION: A patient presents for preoperative clearance. During this encounter, another health concern (other than the reason for which the surgery is scheduled) arises, and the physician orders additional testing. Can we charge for both the preoperative consult and the evaluation and management (E/M) service?

ANSWER: Yes, you can report both services as long as you append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code and then link the E/M code to the diagnosis code for that additional health concern.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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