Urology Coding Alert

Two recent changes one in the CPT Codes 2002 global surgery definition and another last year in the Medicare Carriers Manual allow payment for preoperative examinations and diagnostic tests conducted for medical necessity outside the global surgical package. The diagnosis codes listed must prove medical necessity for the procedure and must not be deemed routine care. CPT Changes The 2002 CPT directive on the global surgical package says that "subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)" is included in the global surgical package and will not be reimbursed.

This verbiage implies that any E/M encounter including history and physical performed outside of that global period can be reported, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. Whether carriers will reimburse for services outside of these restrictions "is a question no one has fully addressed," Ferragamo says. Medicare Changes CMS also indicated last year that E/M services and diagnostic tests not included in the global package are now chargeable and payable services. In Transmittal 1707 (dated May 31, 2001) to the Medicare Carriers Manual, CMS describes which E/M services are included in the global surgical package. If the evaluation is to determine the patient's risk factors before surgery, the E/M is payable under Medicare. However, the examination and diagnostic test must fulfill medical-necessity requirements, and therefore not be a screening. E/M services and diagnostic tests not included in the global surgical package and performed for the purpose of evaluating the patient's risk of perioperative complications and optimizing perioperative care should be billed and considered for payment. Routine care not deemed medically reasonable and necessary will be denied. List Multiple Diagnosis Codes For the primary diagnosis, you should report one of the following:
V72.81 Special investigations and examinations; other specified examinations; preoperative cardiovascular examination V72.82 preoperative respiratory examination V72.83 other specified preoperative examination V72.84 preoperative examination, unspecified.   After the primary diagnosis, any secondary and tertiary diagnoses should be 1) the reason for the proposed surgery and 2) any medical risk factors that may be present. The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative exam (V72.81-V72.84). Most carriers want the V code first, then the code for the condition that prompted surgery, and finally the code for the medical risk that prompted the medical evaluation by the surgeon. Risk Factors Constitute Medical Necessity Certain medical risk factors such as bleeding disorders (286.x, Coagulation defects) malignant hypertension (401.0, Essential hypertension; malignant), and [...]