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Surgery Clearance

  1. #1
    Default Surgery Clearance
    Medical Coding Books
    Good morning! I was just wondering if I could get a little help/insight on coding for surgery clearance. The physician that I am speaking of sees patients for surgery clearance, the visits include a "physical" like exam and the physician fills out a sheet with the findings of the patients visit, signs it and gives it back to the patient to give to the doctor that was requesting the surgery clearance. My question is, is does he use a consult code or e/m code?

  2. #2
    These are just routine pre-op clearances correct? Then it would be an E/M, either established or new depending on the patients status.

    Laura, CPC

  3. #3
    North Carolina
    I agree with Laura. If these are being conducted in a routine manor, it would not be a consult.

    Medicare Manual Chapter 12 30.6.10 G

    "Preoperative consultations are payable for new or established patients performed by any physician or qualified NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening."

  4. #4
    Yes, this is just a routine pre-op clearance. We have been using e/m codes but the doctor just questioned it because he was told by another physician that he uses consult codes. I was just curious on what everyone else felt about it, whether we were coding correctly or not. Thanks!

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