Wiki Pre-Op Physicals - chronic conditions

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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).

mrolf

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I have received conflicting answers on how to bill pre-op H&P for clearance for surgery (Ex: T&A, cataract) by the family physician 1 week prior to surgery in the office on non-medicare patients who have no chronic conditions. Some bill as a 99214 w/ Diag of V72.83 & also the reason for surgery and some bill a preventative code. When billing an established patient visit insurance has been paying. Any help would be greatly appreciated.
 

daniel

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If the physician is providing a H&P for a surgery at the request of another physician then you would use a consult code.

CPT 99241-99245

with

DX: V72.8X with the following conditions the patient may have.


Daniel, CPC
 

mitchellde

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Except it is not a consult. Even if the surgeon request it the surgeon is not asking for an opion regarding an unknow they are requesting an evaluation of the patients medical fitness. The surgeon will make the decision for surgery not the PCP. The PCP cannot consult their own patienmt back after sending them to a surgeon for an evaluation. This is abuse/misuse of the consultation codes and exactly why Medicare is going to cease paying for consultation codes. For the PCP to see and evaluate the patient for a medical evaluation for preop it should be an office encointerestablished patient.
 

daniel

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For now go with the consultation code, as long is all the requirements are met.

Example:From the American Academy of Family Physicians

Preoperative clearance

It's not uncommon for a surgical specialist to request preoperative clearance from the patient's family physician. As with other consultation services, the preoperative clearance consultation should involve a request for opinion or advice. For example, do the comorbid conditions of this patient require any special considerations? Can this patient safely undergo this procedure?

When you report a consultation for preoperative clearance, use the appropriate CPT code for the level of service and setting where the consultation services were rendered as well as diagnosis codes that indicate the necessity of the consultation. Select the appropriate ICD-9 code from the V72.81- V72.84 series (V72.81 for preoperative cardiovascular exam, V72.82 for a preoperative respiratory exam, V72.83 for another specified preoperative exam or V72.84 for an unspecified preoperative exam) and a second diagnosis code to indicate the condition for which surgery is intended. Also code any diagnoses that arise during your consultation.

Medicare guidelines state that if, following a preoperative consultation, the consultant assumes responsibility for managing a portion of the patient's condition(s) during the postoperative period, the consultation codes should not be used. In this situation, you should use the appropriate subsequent hospital care codes to bill for the concurrent care in the hospital setting and use the appropriate established patient visit codes for services provided in the office.

If you perform a postoperative evaluation of a new or established patient at the request of the surgeon, then you may bill the appropriate consultation code for E/M services furnished during the postoperative period. The stipulations are that all of the criteria (the four R's) for the use of the consultation codes must be met and you must not have already performed a preoperative consultation.

You may not bill a consultation if the surgeon asks you simply to manage an aspect of the patient's condition during the postoperative period, because the surgeon is not asking for your opinion or advice in treating the patient. Instead, your services would constitute concurrent care and should be billed using the appropriate subsequent hospital care codes, subsequent nursing facility care codes or office or other outpatient visit codes, depending on the setting. (To learn more about concurrent care coding, see "A Refresher on Medicare and Concurrent Care," FPM, November/December 2005.)
 

LLovett

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I disagree as well. Many pre-op clearances are mandatory screening exams. That does not meet the requirement of a consult. Even for non-Medicare patients it is still abuse to automatically report a consult for a pre-op. If there is truly an issue the surgeon is concerned about, ie they will not schedule surgery until they know the outcome of the visit, that would be a consult. If they have already scheduled the surgery and this is just a formality, it is not a consult.

Laura, CPC, CEMC
 
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Original post

The original post says this is a non-medicare patients who have no chronic conditions (emphasis added by FTB)

So this is a case of a surgeon being lazy and refusing to perform the service for which s/he is being paid. Every procedure includes the appropriate preoperative evaluation of the patient. I would ask the surgeon what procedure code s/he will be using, and code that procedure with a -56 modifier. That perfectly describes the service being provided. Of course the surgeon will need to code the procedure with a -54 modifier, thereby reducing his/her reimbursement appropriately to reflect the fact that s/he did not perform the entire service.

For example CPT 27130 for a total hip replacement has about 10% of the RVU allocated to pre-operative service. So the PCP would code 27130-56 and get about 10% of the allowable fee for that service; the surgeon would code 27130-54 and receive the remaining 90%.

For argument's sake (and to make the math easy) let's say the surgeon fee is $10,000; the insurance allowable is $8,000; the PCP would get $800 for the pre-operative management of this patient and the surgeon would get $7,200 for the surgery plus postoperative care.

Note: my surgeons do ALL their own pre-operative managment UNLESS there is a significant co-morbidity for which they request a consultation from the appropriate specialist (cardiology for example). And even in these cases the surgeon still does the hospital H&P.

This issue just makes my blood boil. I was at a conference recently where a PCP mentioned that an orthopaedic surgeon he knows has bragged "I don't even OWN a stethescope!"

Okay, off my soap box now.

F Tessa Bartels, CPC, CEMC
 

LLovett

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That is an interesting idea Tessa. What happens though when the surgeon bills the global fee? Or if they bill different codes? I have no doubt my primary care docs would love to get a percentage of the surgical procedures instead of just and E/M but it looks like it could get very complicated.

Laura, CPC, CEMC
 
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Laura raises good questions

Okay ... I admit that I am basically working in a closed system, by which I mean it is a large, major, academic medical center with hundreds of docs ... all sharing a med record ... AND sharing a "billing service" where the coders check with each other.

But ... if the PCP's coder/biller is on the ball ... that charge will be in the insurance company's hands before the surgeon even operates. And the surgeon's charge is the one that will get kicked back.

I admit I'm answering partly out of frustration and indignity at the gall of surgeons who refuse to do the basic pre-op evaluation required (and for which they are being paid!).

This type of coding would require the cooperation of both physicians's office staff so that the PCP would have the primary surgery code to use with the -53 modifier. In most cases the actual code does NOT differ from the pre-authorized code, especially when you have a basically healthy patient with no co-morbiditieis and little likelihood of "surprises."

I'm sure the surgeons would NOT like this solution ... but then, they should be performing the pre-operative service on their "healthy" patients themselves.

F Tessa Bartels, CPC, CEMC
 

daniel

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I see where all of you are coming from, and it's good input.

But flip the coin on the other side of this scenario, say the surgeon is an orhto and he is going to do a procedure on a patient with multiple chronic conditions. It's only naturally for the surgeon to send them back to there PCP and make sure he/she is fit for surgery.

Orhto/Any other surgeon have no business evaluating chronic conditions.

Plus Medicare has direct us to use the consult codes when a Pre-Op clearance is request and all the three R's are met.

Either way this is going to be an old debate come next year with medicae not paying on Consults anymore, plus I'm sure the PPO's insurances will follow suit soon.

Reference

Medicare Carriers Manual 15506 states: “Pay for the appropriate consultation code for a pre-operative consultation for a new or established patient performed by any physician at the request of a surgeon, as long as all the requirements for billing the consultation codes are met.”
 
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To daniel

Daniel,
You are right about requesting a consultation for co-morbidities. But the original poster specifically stated that this is a "non-Medicare patient with no chronic conditions" (i.e. healthy patient) for which the surgeon is expecting the PCP to perform the H&P. In such a scenario this is NOT a consultation. And it doesn't merit an established visit code either. There is no medical necessity for the PCP to perform this service, which is an integral part of the surgery and for which the surgeon is being paid.

F Tessa Bartels, CPC, CEMC
 
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