What Really Is the Decision for Surgery
December 29th, 2015 - Seth Canterbury, CPC, ACS-E/MPer the wording in the CPT® book under Modifier 57, the decision-for-surgery visit is the visit at which the physician makes the INITIAL decision-for-surgery. In other words, it’s the visit at which the physician decides that surgery is the best clinical option to treat the patient’s condition.
After this decision is made, the patient may ask for a few days or weeks to consider the surgeon’s recommendation. The patient returns for a f/u visit and essentially says “ok.” That doesn’t mean that this patient agreement visit should now be considered the decision-for-surgery visit. The physician’s decision was already made and now the patient has simply agreed to go along with it.
After the surgeon’s decision, the patient may need a focused evaluation by an outside specialist of some comorbid condition that falls outside of the realm of the surgeon’s expertise to evaluate. The specialist will send an opinion back to the surgeon with a yea or nay vote on proceeding with the surgery. If the decision is “fine by me” then no significant work is required of the surgeon to assimilate this “yes” vote into his consciousness. He simply continues with his already decided-upon plan to treat the patient surgically. This realization that the patient’s comorbid condition does not warrant altering his decision-for-surgery would not constitute a new decision-for-surgery visit. (If the specialist votes “no,” then it is a moot point as no surgery will occur with which the next visit with the surgeon could be considered global.)
After the surgeon’s decision, the patient will always need to have a routine pre-op performed, preferably by the surgeon since he/she is already receiving payment for this service inside his/her global surgical fee. If no reason is found to cancel surgery, the surgery is scheduled. This realization that the patient’s overall health is sufficient to withstand the surgery would not constitute a new decision-for-surgery visit.
The CPT® Assistant of May 2009 clearly says that no further E/Ms should be billed after the initial decision visit relating to clearances, saying that “regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the [routine pre-op clearance] visit is not separately billable as it is included in the surgical package.” The decision-for-surgery was already made. Final decisions to go through with this plan after clearances have been received are part of the pre-op work bundled into the surgery.
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