How Do You Bill for H&P?

Question:

The hospital requires our surgeons to perform and document an H & P prior to the patient having an elective gall bladder surgery. Sometimes it’s done in the office before the surgery and sometimes it’s done on the same day as the procedure. If this H & P is documented, can the E/M be billed? And does it make a difference if it’s done a week before the surgery?

Answer:

A pre-operative H & P, regardless of when it occurs, is included in the global surgical package and is not separately billable. CPT clarified this in 2009 in a CPT Assistant comment, see below:

“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.” (Source CPT May 2009)

*This response is based on the best information available as of 8/14/25.