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Pre-op exam question. Please help!

  1. #1
    Question Pre-op exam question. Please help!
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    Alright, I have a surgeon who is performing cataract surgeries. He does not do the pre-op H&P; the patient's family physician is doing these. The clinic where the H&P's are being done does not want to perform them anymore as they are being bundled to the surgeon's global package and they are not receiving any reimbursement.

    I know that the global package includes the day before the surgery so if the patient were to have their pre-op exam 2 days before the surgery would it still be bundled to the surgery?

    Thanks for your help!
    Missy Heuer CPC, CIRCC, CANPC

  2. #2
    Default
    I have never had this happen.

    Is it one particular payer?

    Laura, CPC, CEMC

  3. #3
    Default
    You know, I am not entirely sure. We do the billing for the CRNA at the surgery center. She called and asked us if we could help clarify this.

    Based upon the cases the I have done, I would say that it is mainly Medicare as most of their patient's are over 65.
    Missy Heuer CPC, CIRCC, CANPC

  4. #4
    Default
    Hmmm..

    I wonder how they are billing and what the rejection is. I don't see how a FP or IM providers E/M service could reject global off of a surgery done by a different specialty. Especially since their bill is prior to the surgery.

    I don't know, this just doesn't sound right to me. If they said the rejection was due to the E/M being a non-covered service, that would make sense, due to a screening dx code. But not global.

    Sorry I'm not much help, I think more info is needed to get a better handle on what is happening.

    Laura, CPC, CEMC

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Medical necessity?
    I'm wondering if there is an element of medical necessity for the denials. That is, if the patient has no complaint other than "pre-op exam" there is no medical necessity for an E/M by the PCP. (Because the "pre-op exam" is covered in the RVUs for the surgery.)

    Now if there is a medical reason for requesting the pre-op eval .. e.g. heart condition ... then the surgeon should be sending a request for consultation and the PCP can code the appropriate consult codes.

    F Tessa Bartels, CPC, CEMC

  6. #6
    Location
    Hartford, CT
    Posts
    723
    Default
    I agree with Tessa, most pre-ops are a requirement of the facility and not the surgeon. If the patient does not have any condition that would require extra work (heart, uncontrolled diabetes, etc) or would pose an extra risk, Medicare does not consider a separate pre-op exam medically necessary.

    Doreen, CPC

  7. #7
    Thumbs up Pre-Op
    The pre-op clearance is tied to the surgery/procedure. If it is performed by the surgeon, it is considered part of the "global fee" for the procedure. Ethically, there is no way to circumvent this.

    If the patient is sent to a specialist of to his/her PCP, for a pre-op clearance, the V code has to be in the 1st dx position, the DX code that is tied to the auth and is the reason for surgery is always in 2nd place and any relevant findings are in 3rd and 4th.
    For example, V72.81 Cardiology Clearance, V72.82 for Respiratory, V72.83 for Other Specified Exam (Diabetes, long-term use of high risk drugs, etc0 followed by the reason for the surgery/procedure and the specified reason for the exam in 3rd position and any incidental finding in 4th) a V72.86 for blood typing would be used only for the lab testing and an E&M visit wouldn't be appropriate as is the same for the V72.6 Lab exam code.
    The E&M would be determined if the patient was a New or Established patient or if there was a written request for a consult to clear this patient for the surgery/procedure.
    If the pre-op is a generral exam that is done in the course of the surgery or procedure, the surgeon or specialist will have to suck it up and not unbundle what is paid for in the global fee.
    Of particular note is that in Work Comp cases, the Diagnosis that is attached to the WC Claim has to be in 2nd position after the Pro-op screen or consult or the consult/E&M visit will not be covered. The finding from the E&M /Consult has to be in 3rd and 4th for WC to cover pre-op clearances.
    This seems difficult for some specialists to understand because if they are seeing this patient for a respiratory clearance and the patient has COPD but the surgery/procedure is being done for a hip or back injury, the Pulmonologists believe the COPD is the reason for the consult not the back or hip injusy. Doesn't matter, the auth is tied to the wC injury, not the COPD and if not billed to address the WC injury, the calim will be denied.

  8. #8
    Default Pre-Op
    I can only tell you how we do it. Our patient sees their surgeon and is set for surgery and an appointment is set up with us (the PCP). We generally do the clearance about a week before the surgery, and the patient has a pre-op clearance form given to them by the surgeon with what tests to be done and why they are having the surgery. We get alot of Medicare cataract surgery requests so as an ex. the doctor gives me the level of service, such as 99243 then is 1) v72.84 (w/o an EKG) 2) 366.9 cataracts and then 3) 250.00 of 401.1 (any diagnosis that necessitates the clearance) . Hope this helps.

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