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Pre-op clearance

  1. #1
    Default Pre-op clearance
    Exam Training Packages
    I have a couple questions relating to a Family Physician's office. I do quarterly audits for each physician and just recently met with our family physician within our group.

    Question #1 Upon asking the physician if he ever does any consults, he said, "No, but I get asked a lot to do pre-op clearances, so in my mind that is a consult." My question is, as long as he is meeting the consult documentation requirements, can we code this as a consult?

    Question #2 Along with all the auditing, I have taken on an additional task of creating forms that better meet the physician's needs for documentation reasons. As I'm creating these forms, in which the patient will fill out a portion of, I am thinking the patient really needs to sign the form. Otherwise, that information could belong to anyone. My question to this is, upon the patient signing the form what would be a proper verbage to use on the form so the patient knows what they are signing for. I already have one simple sentence of "I authorize the provision of reasonable and proper medical care by today's standards." And then the patient would sign. Is that good enough, or should something else be added? Any suggestions would be great.
    Tiffany Fischer, CPC, CEMC

  2. #2
    Columbia, MO
    Pre op clearance is not a consult it is a clearance which is an OV or the procedure code planned plus the 56 modifier.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default Pre-Op Clearance
    If a doctor from a different practice is asked to clear a patient for surgery, as long as you have a written request from the surgeon that indicates the reason the patient needs a pre-op clearance exam, your doctor examines the pateint and sends a written report back to the surgeon, I believe it is a consult (except for Medicare patients - see new rules about no longer paying for consults)

    Take a look at the following article.
    Heather Winters, CPC, CFPC

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