Wiki Pre-Op H&P visit billed by surgeon

[nancyenos]

I have been seeing several instances where a surgeon is seeing the patient in the office a week to 2 days before scheduled surgery and billing the "Pre-op clearance" visit and dictating the H&P into the hospital system.

They are billing a 99213-99215 with a chief complaint of "Pre-op clearance" and saying they CAN bill for this visit because the global surgery definition says "E/M on the the day before or the day of surgery" is included.

The pre-op allowable of the global split clearly pays for this. Can anyone point out some good documentation that I can refer to with these surgeons?

Thanks

 

[RebeccaWoodward*]

Charging for Pre-Op H&Ps

Q I have coded for 30 years and still am not comfortable with what to do about history and physicals done preoperatively. I pretty much stopped charging for H&P when I read an article that stated, “If the H&P is done for hospital regulations then you cannot charge.” But now I hear other practices are charging for pre-op exams. What's the real story?

A Medicare will pay for preoperative clearance exams if the exam is medically necessary (not just done because the hospital says you should), isn't covered under the global, and meets the documentation requirements of the service billed. Look at page 16 of this transmittal, which spells out Medicare's policy.

Of course, many of the H&Ps you may be doing are covered under the global. This is defined in CPT in the comments that define the surgical package. You'll find them at the front of the surgical codes in your CPT book. The basics:
An E&M on the day of or the day prior to surgery is included in the surgical package unless that is the visit that led to the decision for surgery.


Additional reimbursement for preoperative E&Ms is usually allowed prior to the decision for surgery to establish the need for surgery. This is what CPT says, but your payers may have their own rules. You'll have to check your contracts and denial codes for those.

http://www.cms.hhs.gov/transmittals/downloads/R788CP.pdf

 

[kevbshields]

Like Rebecca, I do not feel comfortable with this "new" spin on Pre-ops.

I hear more and more (yes, I realize this is anecdotal) about practices "scheduling out" these pre-op exams. In truth, these exams are not usually for "clearance," as the patient is being seen in/by Medicine for those services. The Surgeons are bringing patients into their office for what I call a "Surgical Preview".

Justifying the medical necessity of these is dubious, at best. I also think the providers have tried to muddy the waters on the "decision for surgery" phrasing. In truth, a decision for surgery can occur a long time before that service takes place--not only the day beforehand.

This practice is concerning, CMS commentary & opinion aside. I'd really like to see OIG and PI programs look into this practice. It seems questionable.

 

[Treetoad]

Unless the visit is truly a "decision for surgery", the H&P shouldn't be charged. Just because the hospital requires an H&P prior to surgery, doesn't mean it's a chargeable service. The RVUs for the procedure takes into account pre-op work.