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Preop clearance on New patient

  1. Default Preop clearance on New patient
    Medical Coding Books
    I have an MD that wants to charge a consultation for a new patient Preop clearance.

    PT is also establishing care w/ this provider.

    MD does full new patient exam to "establish care" plus a "preop consultation & clearance"

    I feel this should be billed out as a New patient rather than Consultation as it is establishing care, but also note that a specific consultation was also asked for from the Ortho. physician.

    can someone either justify my thinking or tell me why i'm wrong?
    Rachell Lindley, CPC
    Multispecialty Clinic Coding
    Internal Medicine
    General Surgery
    Family Medicine

  2. #2
    Ok, if it truly is a consult, that in and of itself establishes care with the provider. There would not be a second E/M code justified in my opinion.

    If it is just a routine pre-op clearance then that is a new patient E/M, which again establishes care.

    I am not seeing how he could get 2 E/M services of this type, new patient 99201-99205 and consult 99241-99245, in one visit. You can't use the information twice and they both require all 3 of 3 to level.

    Just my opinion,

    Laura, CPC, CEMC

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