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Medical clearance

  1. Question Medical clearance
    Clearnace Sale
    Could someone help me how do I have to code a visit, at the physician office, where the patient is seen to give him a medical clearance for a surgery? I use the office visit code but I dont found the code (ICD 9CM)for a diagnosis like "medical clearance for surgery" The Dr perform a physical check up, labs and EKG.
    Thank you

  2. #2
    north seattle wa
    Default medical clearance
    It depends on what insurance they have. Medicare wants the condition for which the service was requested as well as the pre-op V code- V72.81-V72.84. If the pt was sent to your doc because of high blood pressure and the surgeon wanted them cleared before surgery, according to Medicare you would bill for E&M service and the 401.9 for the high blood pressure first with the preo-op V code second. You don't use the reason the pt is having the surgery.
    Here is the verbage that Medicare put out:
    The new instructions from CMS are very explicit. Medical preoperative examinations and diagnostic tests done by, or at the request of, the attending surgeon will be paid by Medicare, assuming, of course, that the carrier determines the services to be "medically necessary." All such claims must be accompanied by the appropriate ICD-9 code for preoperative examination (i.e., V72.81-V72.84). Additionally, you must document on the claim the appropriate ICD-9 code for the condition that prompted surgery. If there are other diagnoses and conditions affecting the patient, you should also document those on the claim.

    Hope this helps.

  3. #3
    Default Attention
    You can code all Pre - Op clearances as CONSULTATION CODES. Just be sure you have a request form from the Dr. or Hospital. Suggest you surf the web and you'll see something on there pertaining to this. Check out AAFP, and surf around there also. Plus use, V72.81-V72.84 for the DX and any other conditions brought up after.

  4. #4
    You would bill a consultation code for a Pre-Op Clearance if, and only if, you have a request from requestor with a specific medical reason. So if the reason is the person is having cataract surgery and they want clearance, that isnt enough. However if your physician is being asked by the requestor for pre-op clearance due to the patients HTN, bingo we got it!.
    Michelle Wood, RHIT, CCS-P, CPC, CPMA, CEMC, AAPC Fellow
    2018 AAPC Columbus, Ohio Chapter Treasurer

  5. #5
    Moore Local Chapter
    Default medical clearance
    What if the patinet is wanting medical clearance to go back to work? How would that be coded?

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