Wiki Pre-op Exam Coding

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kcaskey03

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I have a question on how to correctly code a pre-op exam. I work at a family practice office and we occasionally do pre-op exams for surgeons that request the preop exam. Do we code an E&M level (9921X) or do I need to get the surgical code that the surgeon will be using and bill the surgical CPT code with a modifer 56 ? Ive tried to do some research on this and I've heard people doing it both ways. If the answer is to use the surgical CPT code, what if the surgery changes into a more extensive surgery... this may change the CPT code, does that affect anything? I would appreciate anyones help! :)
 
The absolute correct way to do this is the use of the surgery code with the 56 modifier but you must have proof in the chart that this patient was referred for this preop by the surgeon. If not referred by the surgeon then it is an office visit level. If you look in your carriers guide there should be something regarding the use of this modifier. BCBS states they will reimburse 15% of the surgical allowable for the use of this modifier.
 
I dont agree with billing this with a 56 modifier, a 56 is for preoperative management. The pcp is not doing the preop management, they are simply doing the clearance. The surgeon is doing the preop management by evaluating the patient's surgical problem and advising them on the risks and benefits of surgery.
 
The surgeon ordinarily provides that service in the first encounter and bills an office encounter usually with a 57 modifier, but then send the patient to the PCP for preop, that then is the preoperative management. To check the patient over prior to a surgery at the request of the surgeon.
 
We do many pre-ops in the office and it is a consultation depending on the insurance as some do not pay for them,otherwise it is an E/M level, I don't see how you can bill for the surgical procedure that is being done by another physcian, your provider is not doing that procedure and cannot bill for it.
 
Pre op is not a consult if this is your patient. The surgeon is not asking you for an opinion, they are wanting a report of the patient's medical condition at this time. You are not making a decision about surgery. This was one of the issues cited by CMS as the reason they decided to disallow consultations. You are not billing for the surgery you are billing for the preoperative component. If the surgeon requests that you perform the preoperative examination then they are asking you to provide the preoperative part of the surgery. The surgical global consists of 3 parts, the preop, the surgery, and the post op. These can each be split out for separate reimbursement using modifiers 54,55,56. If the surgeon is telling your physician to perform the pre operative exam then obviously the surgeon is not going to do it so why should the surgeon get that part of the global fee. That is why the AMA created these modifiers and they attach to the surgical code.
 
I just thought I would add this from the Blue Cross Manual:
· Modifier 56 is reported when one physician performed the preoperative care and
evaluation and another physician performed the surgical procedure. Modifier 56 is
appended to the surgical code. The physician is paid a portion of the global
package.
· Modifiers 56 must only be appended to the surgical procedure codes.
· Procedure codes with modifier 56 appended will price at 15% of the allowable
charge.

There are many others and the percentage is different but somewhere between 10 to 15% of the surgical allowable.
 
I still totally disagree, the pcp is not providing the preop care. We sometimes see a patient 5 or 6 times before deciding on surgery, the dr may order pt, epidurals, etc before deciding on surgery, the pcp is not treating the patient for the operative problem, only doing the clearance which is not preoperative management. Making sure a patient can make it through anesthesia by doing a cardiac clearance is not preoperative management of a lumbar disc herniation. Clearance may be required from 3 different physicians, the pcp for general, pulmonologist for lungs and cardiologist. The are not treating the patient for the operative problem or doing any type of management, they are only doing the clearance. An example, to me of using the 56 modifier would be if a patient went to a neurosurgeon in another state for the conservative managemtn and had the surgery done by our neurosurgeon. Our neurosurgeon did the surgery only but non of the preop management.
 
penguins11 said:
I still totally disagree, the pcp is not providing the preop care. We sometimes see a patient 5 or 6 times before deciding on surgery, the dr may order pt, epidurals, etc before deciding on surgery, the pcp is not treating the patient for the operative problem, only doing the clearance which is not preoperative management. Making sure a patient can make it through anesthesia by doing a cardiac clearance is not preoperative management of a lumbar disc herniation. Clearance may be required from 3 different physicians, the pcp for general, pulmonologist for lungs and cardiologist. The are not treating the patient for the operative problem or doing any type of management, they are only doing the clearance. An example, to me of using the 56 modifier would be if a patient went to a neurosurgeon in another state for the conservative managemtn and had the surgery done by our neurosurgeon. Our neurosurgeon did the surgery only but non of the preop management.
Click to expand...

This is true. The OB/Gyn docs I worked for did their own pre-op visit for the surgery, but sometimes especially on older patients, they would request a pre-op clearance from the PCP. This is not a pre-op visit because it is unrelated to the reason for the surgery. Frequently the PCP is checking the cardio or respiratory status of the patient to see if they can tolerate anesthesia and surgery. The PCP bills an E/M visit with diagnosis code from V72.8x series where there are specific pre-procedureal diagnosis codes.

The use of the surgery code with the 56 modifier is intended to be used when one provider provides ALL the pre-op services, which would include the decision for surgery.
 
And you are NOT coding for this?

penguins11 said:
I still totally disagree, the pcp is not providing the preop care. We sometimes see a patient 5 or 6 times before deciding on surgery, the dr may order pt, epidurals, etc before deciding on surgery, the pcp is not treating the patient for the operative problem, only doing the clearance which is not preoperative management. Making sure a patient can make it through anesthesia by doing a cardiac clearance is not preoperative management of a lumbar disc herniation. Clearance may be required from 3 different physicians, the pcp for general, pulmonologist for lungs and cardiologist. The are not treating the patient for the operative problem or doing any type of management, they are only doing the clearance. An example, to me of using the 56 modifier would be if a patient went to a neurosurgeon in another state for the conservative managemtn and had the surgery done by our neurosurgeon. Our neurosurgeon did the surgery only but non of the preop management.
Click to expand...

Penquins ... the global surgery package INCLUDES the initial hospital visit or pre-op exam. I realize that your surgeons have done considerable pre-operative work before deciding to do surgery (or the extent of the surgery), however, all that was coded and paid separately.

When I state that the PCP should code the surgery with a -56 modifier it is because the SURGEON is NOT doing the hospital H&P at all, but leaving that entire piece to the PCP. (I know of one ortho surgeon who has bragged that he doesn't even OWN a stethescope.)

Certainly if your surgeon is requesting a consultation (i.e. advice/opinion on co-morbidities) for issues s/he does not typically deal with, it's appropriate for the consulting physician to code the E/M as per documentation and guidelines (consult codes are still covered by most payers, just not Medicare or other government payers).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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I never indicated that we bill for the preop exam, we bill for all of the office visits up to the preop exam, The preop is a $0 charge. Also, the pcp's never do the H&P's for our patients. If we admit to the hospital for a surgery our surgeon's do the H&P. The pcp is not the admitting physician, our surgeon is the admitting. I have never heard of the pcp dictating the H&P and doing the admit for a planned surgery. All of the specialists admitting a patient for a planned surgery in our area dictate their own H&P's, not the pcp.
 
Specialists doing and H&P, that is unheard of in my area...

The specialists in my area do not admit patients at all, they make the primary admit them and stay on the case so all they have to do is their surgical notes and follow up. The primary providers has to do the H&P and the discharge. But they do not coordinate billing with the primary offices so they can bill appropriately with the surgical code.

This is wrong. This needs to change. It is a culture issue that I have been dealing with for years.

There are times when the specialist truly does consult a primary for clearance. In those cases the consult code or other E/M would be appropriate. In those cases there will be an actual reason for the visit not just "preop clearance". They should be asking for "cardiac clearance" and the surgery not even scheduled until the clearance is received. The majority of the time though, the specialists has no reason for sending them to their primary othere than there has to be an H&P on the chart. They plan to do the surgery no matter what the other provider says.

Just my 2 cents,

Laura, CPC, CPMA, CEMC
 
penguins11 said:
I never indicated that we bill for the preop exam, we bill for all of the office visits up to the preop exam, The preop is a $0 charge. Also, the pcp's never do the H&P's for our patients. If we admit to the hospital for a surgery our surgeon's do the H&P. The pcp is not the admitting physician, our surgeon is the admitting. I have never heard of the pcp dictating the H&P and doing the admit for a planned surgery. All of the specialists admitting a patient for a planned surgery in our area dictate their own H&P's, not the pcp.
Click to expand...

I agree that in this situation the PCP is not dictating an H&P for admit, they are doing an exam and reporting to the specialist if the patient is, or is not, healthy enough for surgery and anesthesia. This is a preop clearance that is separate from the acutal preop visit with the specialist.

If, however, there is a situation where a specialist has a PCP doing the preop work, and the PCP dictates the H&P that is used to admit the patient to the hospital and the specialist does not see the patient for a preop visit, then perhaps the surgery code with the 56 modifier is more accurately describing the work that was done. That is not the way any specialist I have worked with does things, but it is certainly a possible scenario.
 
Thanks, Arlene. I think you had it right the first time. Our PCP's do pre-op clearances and bill E/M visits. I've never seen Mod 56 used by any of our practices (FP or specialty) in any situation.
 
This really is quite simple:

The PCP is being asked for an opinion on the ability of the patient to have surgery - hence pre-op clearance.

They are not performing pre-operative management.

they are providing a report to clear the patient based on the surgeon asking for the clearance.

Therefore you would bill a Consultation Code and if the insurance carrier does not accept these then you would bill a new/established patient. If the doctor is the PCP of the patient - the MD can still bill a consultation code.

Cannot be any clearer that this

Mike
 
kcaskey03 said:
I have a question on how to correctly code a pre-op exam. I work at a family practice office and we occasionally do pre-op exams for surgeons that request the preop exam. Do we code an E&M level (9921X) or do I need to get the surgical code that the surgeon will be using and bill the surgical CPT code with a modifer 56 ? Ive tried to do some research on this and I've heard people doing it both ways. If the answer is to use the surgical CPT code, what if the surgery changes into a more extensive surgery... this may change the CPT code, does that affect anything? I would appreciate anyones help! :)
Click to expand...
The proper way for a family physician/primary care physician to bill this surgical clearance is with an E/M code and ICD9 code V72.84. If the physician also does an EKG, you would bill the appropriate EKG CPT with ICD9 V72.81.
Modifier 56 is intended for use when a surgeon does all the workup for the surgery, but a different surgeon actually does the procedure.
 
Preop exams -

For those insurers that still recognize consultations we apply the following: Preoperative consultations are payable for new or established patients performed by any physician or NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening.
Medical preoperative exams and preoperative diagnostic tests are payable if they are medically necessary and meet the documentation requirements of the service billed.
All preoperative claims must be accompanied by the appropriate ICD-9 code for Preoperative examination (V72.81-V72.84). Additionally, report DX code for the condition(s) that prompted the surgery must also be reported. Other DX and conditions affecting the patient should also be reported.
A physician or NPP cannot bill either an E/M or consultation for preop visit if the patient doesn't have any known underlying conditions. The E/M or consultation in the absence of signs or symptoms of a disease or illness would be screening and not covered.Note: For insurers that don't recognzie consultations - we report a new or established office visit to report a pre-op clearance visit and apply the preop exam dx and reason for the surgery and other dx that are relevant.


NHIC E/M GL 2011 Medicare Manual
 
This is the information I've handed out to my family practitioners when they're performing a pre-op H&P....it may contain more than you were looking for, but just disregard what you don't want.

Rita Conley, CPC, CEMC

PREOPERATIVE CONSULTS: There seems to have been confusion of late surrounding pre-op H&Ps and when it is, and is not, appropriate to bill for a consult vs. established/new patient office visit. Please see below for guidance.

BILL A CONSULT when the surgeon requests a consult for pre-op clearance due to a patient's chronic underlying medical conditions; this visit would qualify for a consult, as the medical necessity is supported by the potential effect the underlying condition(s) could have upon the surgery.

DO NOT BILL A PREOP CONSULT when a patient comes to the office with a surgical pre-op form and is seen for a pre-op H&P (without a specific consult request from the surgeon) -- this visit would qualify for a new or established patient E/M (evaluation and management).

DO NOT BILL A PREOP CONSULT if a surgeon requests a consult for a pre-op clearance simply because

(a) he/she does not perform them in the office, AND
(b) the patient has no chronic underlying medical condition for which surgical clearance is necessary.

This visit would qualify for a new/established patient E/M only

RATIONALE:
One cannot assume a consult....the surgeon needs to request it and document the request in his/her notes/orders, etc.

Remember the three R's--Request, Render, Report--that are required in order to bill a consult.

Prevent med E/Ms cannot be utilized for pre-op H&Ps....the visit would be billed with either a new/established or consult code.

Selecting your level of E/M based on key components vs. time depends on how the visit evolves. To select the appropriate level of service, all three key components (history, physical examination, medical decision making) must be met, or the code may be reported based on time if more than 50% of the total face-to-face service is spent in counseling or coordination of care.

Remember also when billing for pre-op H&Ps, assign diagnoses as follows:
1. V72.83 (pre-procedural general PE)
2. Dx best describing reason for surgery.
3. Co-morbid conditions that may have an impact on surgery.
 
So to add more confusion to the mix, does anyone know the proper way to code this scenario? Our Hospitalist is asked to evaluate a patient in the ER for admission. He writes the order for admission and asks a specialist- let's say Ortho to evaluate let's say a hip fracture. Ortho decides the patient needs surgery and asks the Hospitalist to do pre-op clearance. I think the Hospitalist should bill an initial hospital visit on day one, and a subsequent for the pre-op clearance if on a separate dos. But what if this is all done on the same dos, would it be appropriate to bill the consult code in place of the initial visit? Of course for those carriers who aren't allowing consult codes it would be the same code either way.

Thanks.
 
pre-op

I currently work for a family practice and understand the need for clarity on pre-op coding. I have always coded with a consultation code with valid request from surgeon and use v72.8x dx codes. No modifiers unless add'l problems not related to the consult-I'd add an ov with mod 25. I am totally doing this wrong right? HELP:confused:
 
Pre-op's

In my practice we make sure if we are billing Medicare we will bill a regular office visit, new or established since medicare do not pay for consultations. For commercial Insurances if the provider is assesing chronic conditions we bill a Consultation code as long as the report meets all requirements for this (RRR). No modifiers appended unless we do an EKG. In this case we append modifier 25. And the ICD-9 code tu use is the
V72.8__ .
 
Celestine Lewis,CPC

I am a Radiology Coder, can anyone give me a Dx code for Ventricular Reflux of the Tracer. i couldn't find anything except the reflux code.

thanks!
 
A pre-op visit requires medical necessity in order for the provider to bill an E/M code (99212-99205). CMS is very clear on this, and MAC's like Noridian, have an LCD clearly spelling out the requirements. The visit must be scheduled to evaluate the risk factors for a surgery, ie...COPD, smoking, HTN and then provide clearance for identified risk factor(s). Medical necessity is not met when a surgeon requests routine pre op testing such as labs, xrays, ekgs. This preop testing is part of the surgeon's global payment and must not be referred to a PCP. The patient should be sent to the hospital for this routine work. Surgeons need to be educated as well because they are used to delegating this 'routine' work onto the PCP and, therefore, balk when they are told this is inappropriate.

Lillian
CPC, CPMA
 
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shirleyharris said:
So to add more confusion to the mix, does anyone know the proper way to code this scenario? Our Hospitalist is asked to evaluate a patient in the ER for admission. He writes the order for admission and asks a specialist- let's say Ortho to evaluate let's say a hip fracture. Ortho decides the patient needs surgery and asks the Hospitalist to do pre-op clearance. I think the Hospitalist should bill an initial hospital visit on day one, and a subsequent for the pre-op clearance if on a separate dos. But what if this is all done on the same dos, would it be appropriate to bill the consult code in place of the initial visit? Of course for those carriers who aren't allowing consult codes it would be the same code either way.

Thanks.
Click to expand...

In this scenario, the hospitalist is doing an H&P to admit the patient anyway, he should not get additional for preop clearance. Hospitalist should bill appropriate codes for admitting and following the patient.
 
Absolutely disagree - the PCP is not performing the pre-op care as they are only supplying information requested by the surgeon. The surgeon is asking for an opinion as to whether the patient is eligible for surgery based on their ability to withstand the surgery. Pre-op management would be if one physician was caring for the patient and the decision was to allow another surgeon to perform the surgery.
 
Pre-Op Exam

In our case (ophthalmology), I am not sure how the primary care doctor could examine the eyes, perform a slit exam, determine if there is a catarat, determine the type, determine if meets the medicaly necessity criteria, perform the test for lens measurement, etc. When we have done all of these things and determined that, yes, this patient meets all medical requirements for the surgery, we then post the surgery at some time in the future, usualy 3 to 4 weeks later. This completes the pre-op exam. Then before the surgery, the surgical facility requires that the patient be"cleared" for surgery, i.e.: no heart or chest problems, not blood sugar problems, etc.


If the patient has been in to see the primary care physician, then the only thing needed is a brief form detailing the results of that visit. If not, then a brief exam is required to determine clearance for surgery.

Hope this helps.

Bobbie Sox, Practice Administrator
The Eye Center PA
Columbia SC
 
The ophthalmologist may do the workup from the eye perspective. However, if they are concerned about the patient being able to tolerate the procedure (anesthesia, etc), they may ask a PCP for surgical clearance. At this point the PCP has been asked for their opinion and would bill a consult unless the insurance carrier does not accept consults at which point they would then bill a new/established patient.
 
I have a question: I work for a orthopedics office and I was wondering how do I bill for a post op visit but the surgery was done by another doctor in a differnt state?
 
Are you taking care of the patient post-operatively - in other words the whole global period is your responsibility - then you would use the surgical code with modifier 55

If the patient happens to be traveling and there is a problem during the post op period, then I would bill and office visit
 
After reading all this... I am so confused! Our dilemma is : Surgeon sees patient, decides for surgery, patient comes to hospital and seen by a PA for preop exam (no medical necessity/reason for clearance stated), PA bills out New patient with V72.83. Is this appropriate?
 
jk2003 said:
After reading all this... I am so confused! Our dilemma is : Surgeon sees patient, decides for surgery, patient comes to hospital and seen by a PA for preop exam (no medical necessity/reason for clearance stated), PA bills out New patient with V72.83. Is this appropriate?
Click to expand...

This is absolutely not appropriate. The history that is done is this situation is generally required by the facility, and no, there's no true "medical necessity" for it. It is included in the global surgery charges and should not be billed separately.
 
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