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Pre op consultation

  1. #1
    Default Pre op consultation
    Medical Coding Books
    Scenerio: We refer patient to ortho for evaluation of problem. They want to perform surgery. They send us a written request for a pre-op PE listing as a dx the reason for sx. We perform Pre-op pe and then issue a written letter back to ortho indicating patient is cleared for sx and listing patient's other chronic conditions that may tie into the patient's care.

    Does the written request from the Ortho have to have the patient's other chronic conditions listed as a reason for the pre-op in order to qualify as a consultation? In other words, is the listing of only the patien'ts dx that THEY are treating sufficient or must they also document other chronic conditions they want evaluated that prompted the need for a pre-op pe in order for it to qualify as a consultation? Or as long as I have a written request, an exam and a written response back to the ortho am I ok to bill a consultation with a vcode for unspecified pre op exam? Thanks
    Heather Winters, CPC, CFPC

  2. #2
    Tampa, Florida
    when we do a pre-op, we request the specialist to send over documents of why the pt is having the sx along with the pre-op request. this way we can document in the office notes and we charge a consult 99244 and use a V code pre-op physical code for the Dx.

    Nickie, CPC

  3. Default
    The specialist needs to give you a medical condition that they are concerned with. Not something they treat but what you are treating them for and why you need to clear them. We have been doing this for about 1.5 years and at first the speicialists gave us a hard time but it is better now. This is how we were told to do it directly by cms. Hope this helps.
    Nicole wessell, b.s., cpc

  4. #4
    Default Pre -OP Consult
    So it is not enough for them to request that the patient have a pre-op exam. They must specify the condition that prompts their concern (i.e. underlying DM or COPD etc.) in the request for clearance exam?
    Heather Winters, CPC, CFPC

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