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Pre-op Exam

  1. Default Pre-op Exam
    Medical Coding Books
    What CPT code do I use for a pre-op exam done by the patient's PCP?
    It was not a referral.

  2. #2
    Look at CPT 99243 or 99244. Hope this helps!

    Teresa Collins, CPC

  3. #3
    If the visit doesn't qualify for a consult, use the appropriate E/M: 99201-99205 or 99211-99215.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    National Advisory Board Member 2018-2021, Region 6 Great Lakes
    Minneapolis AAPC Chapter, Education Officer 2018
    AHIMA ICD-10-CM/PCS Trainer
    AAPC National ICD-10 Trainer

  4. #4
    Milwaukee WI
    Default What's the chief complaint?
    If this is not a request for a consult from the surgeon who will be admitting the patient, then what is the medical necessity of the visit?

    The RVUs for any surgical procedure INCLUDE the appropriate pre-operative evaluation of the patient. The surgeon should be performing this service. I know, the surgeons say they don't get paid for it ... but they DO .. it's part of the reimbursement of the procedure.

    If the patient has some underlying condition that requires a consult from the PCP then an official request for consult should be forthcoming from the surgeon and the service billed as a consultation, with appropriate report back to the surgeon.

    The surgeons I work for do their own pre-op exams, unless there is some significant co-morbidity issue for which they require a consultation.

    If there is no request for a consultation, and there is no complaint, then you have no reason to see the patient and no E/M.

    F Tessa Bartels, CPC, CEMC

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