Pre-procedure Exams


Louisville, KY
Best answers
My Supervisor posed an interesting scenario for me to research:

Where is it stated that prior to induction of Anesthesia (for diagnostic services—e.g., endoscopy, IR, etc), the performing physician must document examination of the patient and/or determine the appropriateness of patient to receive anesthesia or assess the patient condition? (That is, the endoscopist, etc must document the patient suitable for the procedure with some form of identifiable E/M note.)

Right off the top of my head, I'm saying for diagnostic services that isn't necessarily required. For example, how many times do we see diagnostic breast cyst aspiration done in IR when that Radiologist is not doing any sort of assessment on the patient, outside the minimal required to perform the service?

In addition, is clearance or written request by the PCP sufficient to satisfy this component? How much is enough? Here I'm leaning toward saying that if the PCP is requesting the service, ordering the service or forwarding the patient onto that diagnostic service, then one can infer the PCP has cleared the patient for such exams (and required anesth.).

Any comments, hunches, suggestions would be appreciated. I'll be researching it this weekend . . . see what I can stir up.

Thanks in advance!

According to both the ACR and ASG (Gastro), there are standards for the clinical evaluation of the patient prior to induction. However, that record may be incorporated into the formal report and does not have to stand alone or anything of the like.

The "billability" of these things is a hot topic I'm sure. We, personally, maintain a prudent approach, that the service should not be separately billed (and in most instances there will not exist enough documentation to support an E/M anyhow).

What I discovered was that the physician professional groups are useful when appealing to a provider that may not meet the minimum standards set out. Always helpful to have a clinical commentary on documentation...