Wiki Pre-op Clearance

[chayawieder]

Can anyone tell me how you code both dx and cpt for a pre op clearance? I was told that I should never put the Vcode for pre-op, just do a regular E&M visit cpt and the diagnosis code of the disease that is causing the upcoming surgery. I don't understand why insurance companies shouldn't pay a provider who does an ekg etc and clears a patient for surgery?

 

[twcfpc]

I follow what Medicare Part B wants as much as possible. For EKG and if a chest x-ray is done I use the V codes with few denials. For labs I ask my providers for a valid dx to include with the V code. If it's an outside order, I'll ask the ordering provider for a valid dx and let them know the ins co won't cover the pre-op. Sometimes the pt is blessed with good health and there is no other dx. Your ABNs are your best line of defense. Hope this helps!

http://www.wpsmedicare.com/j5macpartb/claims/submission/pre-operative-clearance-surgery.shtml

Pre-Operative Clearance for Surgery
All patients do not medically require a pre-operative clearance for surgery separate from the evaluation by the surgeon. Patients with associated co-morbidities, other diagnosis, etc., may require an additional evaluation by someone other than the surgeon to determine their suitability for surgery. Medicare does not make payment for pre-operative clearance for surgery on a routine basis.

When there is no medical necessity for Medicare payment, append Modifier GY to the evaluation and management (E/M) procedure code. Although it is not required, we suggest providers use an Advance Beneficiary Notice of Non-Coverage (ABN) on a voluntary basis to alert the patient to Medicare's anticipated denial of the service. The GY indicates the service is statutorily excluded.

When billing for this service when the patient's condition requires the additional evaluation, the provider should submit the claim choosing the most accurate E/M service to reflect the level of services provided. This diagnosis information should have the first diagnosis as the illness, condition, or injury requiring the evaluation, the second showing a pre-operative diagnosis code and then third, the reason for the surgery.

 

[AmandaBriggs]

There is actually a coding guideline for this in ICD-9. It is section IV.N and states, "For patients receiving preoperative evaluations only, sequence first a code from category V72.8, Other specified examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation." These are usually problem-based visits. Our clinic uses E/M codes from the 99201-99205, 99211-99215 or if the criteria for a consultation is met then codes from 99241-99245 may apply.