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Internal Medicine Coding Alert

Reader Question:

Use Consult Codes for Some Pre-Op Visits

Published on Fri Aug 01, 2003 Print Friendly and PDF PDF

Question: A Medicare patient of ours is going in for surgery, and the surgeon requested that the patient see his internist to have a history and physical done prior to the operation. Which procedure code and diagnosis code should I use for this exam if he only came in for the history and physical?

Virginia Subscriber

Answer: Usually in this situation, the surgeon is seeking the internist's opinion on whether the patient is fit for surgery. If you document this request in the patient's medical record and provide a written report to the requesting surgeon, you should be able to report these preoperative visits using a consultation code. If the service is done in the office or other outpatient setting, use an office consultation code (99241-99245); if it is provided in the hospital, use an initial inpatient consultation code (99251-99255).
 
If the service does not meet the definition of a consultation, you will need to use another appropriate E/M code (for example, 99201-99215). Such nonglobal preoperative examinations are payable if they are medically necessary and meet the documentation and other requirements for the service billed.
 
In either case, you should use the appropriate ICD-9 code for preoperative examination, V72.81-V72.84. And, you should use the appropriate ICD-9 code for the condition that prompted surgery. If there are other diagnoses and conditions affecting the patient (such as comorbid conditions like hypertension or diabetes), you should also document those on the claim. For more information on Medicare's policy regarding preoperative services, see section 15047 of the Medicare Carriers Manual online at http://cms.hhs.gov/manuals/14_car/3b15000.asp#_15047_0.

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