Pre-op by pcp for healthy adult

chasgiv4

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Thanks in advance to any help.

I have been researching but can't find any direct information regarding this. Not on CMS and not in the forums. It's as though I have to interpret what is allowed and what is not.

Surgeons are constantly requesting pre-op clearance for surgeries and often for healthy patients with no ailments and no problems and a recent preventive visit. Is the PCP supposed to do a clearance? If so how do you bill for a healthy patient? Is there a way to submit and get paid for a written clearance without seeing the patient since the patient is healthy?

What is the appropriate way to code this CPT and ICD-10?
 

khristinelouise

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I have been looking for info on the same thing and have gotten nowhere. I would be interested in anything you find out. I am at a new job where they bill all pre-op physicals as sick visits which makes no sense to me at all but I am having difficulty convincing them without something to back me up.
 

chasgiv4

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I have been looking for info on the same thing and have gotten nowhere. I would be interested in anything you find out. I am at a new job where they bill all pre-op physicals as sick visits which makes no sense to me at all but I am having difficulty convincing them without something to back me up.

I know it is appropriate to code using the 9921* format but only if it is medically necessary. I don't see how it is medically necessary when the patient is healthy. Still stumped. Hope someone can help for sure. Make sure you subscribe to the thread just in case.
 

syllingk

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I don't see anything wrong with billing a normal e/m code with a pre operative clearance diagnosis as long as you are not the one doing the procedure. Something along the lines of Z01.811.
 

thomas7331

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The question that comes to my mind is how can the patient really be called healthy if they require surgery? Unless it's a cosmetic procedure, the condition that needs surgery will support billing an E&M service. The CMS guidelines do allow for payment of a pre-operative clearance E&M which should be coded with the pre-op Z code as the primary diagnosis and the condition that requires the surgery as the secondary diagnosis.
 

chasgiv4

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The question that comes to my mind is how can the patient really be called healthy if they require surgery? Unless it's a cosmetic procedure, the condition that needs surgery will support billing an E&M service. The CMS guidelines do allow for payment of a pre-operative clearance E&M which should be coded with the pre-op Z code as the primary diagnosis and the condition that requires the surgery as the secondary diagnosis.

I honestly considered that. Makes total sense and thank you for the response. So what if it is cosmetic? Any thoughts there?

Thanks,
 

thomas7331

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If the surgery is cosmetic or otherwise not medically necessary and not a covered benefit of the patient's insurance, then the pre-operative examination would also be not medically necessary and shouldn't be billed to the insurance as an E&M service.
 

ccr888

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Pre-Op Exams

I'm a newbie coder and this is my first response to a thread after nearly two years of reading them only! This is a subject I have researched and would like to share for people who may be hoping to find the answer here.

While I don't always believe everything I find on the web, I believe I have found valid interpretations (one from an AAPC Managing Editor). I will paraphrase from two articles dated after this thread ( 1) https://www.aapc.com/blog/39047-how-to-code-a-preoperative-clearance/ 2) https://gopractice.kareo.com/article/how-should-you-code-pre-op-exams-and-who-can-perform-them).

"According to ICD-10 coding guidelines, pre-op exams to clear a patient for surgery are part of the global surgical package and should NOT be reported separately (i.e., unbundling). UNLESS: the patient has complicating health conditions requiring clearance and management beyond the standard global package H & P. There is generally NO medically necessary reason a healthy patient would require pre-op clearance for surgery." (An otherwise healthy person may need, for instance, knee surgery or cataract surgery.)

Thank you!
Cheryl Roskam, CCA
 

jhendrix08

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I agree with what Thomas said. We are a PCP office (internal medicine) and if a specialist office/surgeon requests that we clear a patient for surgery, our providers will not just sign a clearance form without a face to face with the patient regardless if it's a healthy 20yr old or an older patient with complex health issues. In the rare case that we see a healthy patient for clearance, we would bill a 9921- and use the pre op Z codes with secondary Dx code being the reason for the surgery. More often than not, if the patient will be under anesthesia the surgeon wants an EKG done as well so we are able to bill for that too. We've never had any issues with reimbursement from Medicare. Hope that's helpful.
 

thomas7331

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I'm a newbie coder and this is my first response to a thread after nearly two years of reading them only! This is a subject I have researched and would like to share for people who may be hoping to find the answer here.

While I don't always believe everything I find on the web, I believe I have found valid interpretations (one from an AAPC Managing Editor). I will paraphrase from two articles dated after this thread ( 1) https://www.aapc.com/blog/39047-how-to-code-a-preoperative-clearance/ 2) https://gopractice.kareo.com/article/how-should-you-code-pre-op-exams-and-who-can-perform-them).

"According to ICD-10 coding guidelines, pre-op exams to clear a patient for surgery are part of the global surgical package and should NOT be reported separately (i.e., unbundling). UNLESS: the patient has complicating health conditions requiring clearance and management beyond the standard global package H & P. There is generally NO medically necessary reason a healthy patient would require pre-op clearance for surgery." (An otherwise healthy person may need, for instance, knee surgery or cataract surgery.)

It's interesting to read these articles and I think the general idea that a pre-operative clearance visit should be medical necessary is a valid one, but I have two problems with this.

First of all, a global surgical package by definition is limited to services by the same physician or physicians of that same specialty within the practice. So a visit to a PCP or other specialist requested by a surgeon is by definition not a part of the global package.

Second, I think it is not incumbent upon a coder to know when it is medically necessary or not for a patient to have pre-operative clearance - it is not simply a question of whether or not the patient has a complicating health condition. In fact, some pre-operative visits are specifically done to make sure that a patient does NOT have such a condition - surgeries that pose a high risk may warrant a careful review by a physician of a different specialty just to ensure this is the case.

I find it a little difficult to believe that surgeons would routinely request pre-operative clearance of a PCP for no medically necessary reason and in my career in coding and billing, I have never encountered a payer that asserted this or challenged these visits. Surgeons and PCPs in all of the places I've ever worked never have a lot of extra time on their hands to be scheduling extra patient visits that aren't necessary (unethical providers who want to line their pockets by billing unnecessary services find much more lucrative and efficient ways to do this - just read some of the fraud settlements that are published every week), not to mention that patients would not want to invest the cost and time for these visits either unless they were really important. Honestly, I think that the necessity of a pre-operative visit is a clinical decision that is best left to the provider, and coders have many higher priorities that to be challenging their providers on whether or not such a relatively low-cost and low-frequency service is or is not necessary. Just my two cents!
 
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