Pre-op Physicals - Chronic Conditions
A preoperative history and physician (H&P) is included in the surgical package; however, if the patient has medical conditions that require separate clearance and management beyond the standard H&P, these services can be billed separately. These circumstances might occur if the patient develops a new problem, or experiences another significant change of status, in the days prior to surgery. To establish medical necessity for the visit, you’ll need to link the appropriate diagnosis or signs and symptoms to any E/M service reported.
If the surgeon routinely sends his or her otherwise healthy patients to their primary care physician for clearance—even when there is no medical necessity for that service—the primary care physician is in a tough spot. The clearance is part of the surgical package and shouldn’t be paid twice. Also, there is no medical necessity for a separate E/M service unrelated to the surgery. This means that the primary care physician cannot bill for his or her services, or must send the patient back to the surgeon for this care.
If the surgeon reduces his package payment, the primary care physician can bill for the standard preoperative care; however, the Centers for Medicare & Medicaid Services (CMS) dictates that the surgical package should not routinely be broken. Unless the patient cannot reasonably receive this service from the surgeon because of geographic distance or other factors, Medicare considers it to be abuse to cause unnecessary extra costs and risks in processing two claims (one for the surgeon and one for the primary care physician).