• For the evaluation of the problem, if the procedure is not done that day or the next day.
• For the evaluation of the problem, if it is a minor procedure with a zero or ten day global period, when the Evaluation and Management service is a significant, separately identifiable service, meeting the criteria for using modifier 25. For example, a gynecologist is asked to see a patient with abnormal bleeding, and decides to do an endometrial biopsy on the same day. Both services may be reported and should be paid.
• For the evaluation of a problem, if it is a major procedure with a 90 day global period, and the physician decides at that visit to take the patient to surgery that day or the next day. If the visit meets the requirements for the use of modifier 57, it is a separately reportable (and payable) service.
There are articles in Codapedia about the use modifier 25 and modifier 57.
The surgeon can bill and be paid for an office visit for the purposes of a pre-op H&P after the decision for surgery is made, but before the surgery itself, if the hospital requires it.
This is false. Some surgeons believe they can bill for a visit after the decision for surgery was made and before the surgery for the purpose of the H&P, completing the consent forms and educating the patients about what to expect. This is not a separately payable service and should not be billed.
The CPT® Assistant in May of 2009 answered this question specifically. Here is a quote from their newsletter:
If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package.
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