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Thread: How does everyone else code a pre-op H & P?

  1. #1

    Default How does everyone else code a pre-op H & P?

    Last year our physicians(I work in a family practice) were coding a pre-op H&P as a consult. Now, with the stricker guidelines as well as Medicare's removal of the codes, we are not using the those codes to charge out a pre-op H&P. For Medicare we have been using just regular e/m codes but I am never sure if I should use the pre-op diagnosis V72.83 as primary dx or if I should use the reason for the surgery as the primary diagnosis(ie: carpel tunnel for carpel tunnel surgery).

    Also- for commercial insurances I am never sure if the doctors should use the e/m for this as well or charge out an H&P since they are pretty much doing an annual physical in order to approve the patient for surgery.

    I am curious to know what everyone else has been doing and what your thoughts are on it.
    Thank!!

  2. #2
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    If your physician is being asked by the surgeon for a surgical clearance recommendation/opinion/advice based on existing co-morbidities that your doc is treating, you can still bill a consultation code to the commercial carriers (most are still accepting the 99241-99255 codes through 2010, but you may want to call them to clarify). CPT still requires a request, opinion and report. You will need to use an E&M code for Medicare. I never bill a preventive visit for these kinds of services.

    The diagnosis order is as follows: V72.8x (pre-op exam). This is the reason for the visit, and should be the primary diagnosis code. Secondarily, code the condition that has resulted in surgical intervention, i.e. Arthritis. Lastly, code any co-morbidities addressed by your physician that will impact the surgery, i.e. DM or HTN. If the patient has no existing co-morbidities, sometimes payers will deny based on medical necessity. (for example, does a 19-year-old athlete with no other medical conditions need a pre-op consult??) Maybe not.

  3. #3
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    I still maintan that preop is not a consult if you are this patient's primary care physician. You are being asked to provide a medical report of the patient's condition you are being requested to provide answers to questions or opinions to the surgeon. I know a lot of folks see this different, however this is one of the reasons Medicare made their decision. They stated that it was due to a marked lack of understanding as to what a consultation is. In all likelihood the PCP consulted the surgeon, he cannot then turn around and consult you back. The AMA set the system up to bill preop as the surgical code with the 56 modifier instead of the office visit level. Several carriers will pay this way but you must be in the defined preop global and is different for every carrier. If you are outside the global preop time then most carriers instruct to use a regular OV and not a consult. Just my 2 cents.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4

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    What surgical code are you talking about when you say "bill preop code as a surgical code with a 56 modifier"? I agree with Michelle that a pre op is not a consult, especially with the new 2010 guidelines.

  5. #5
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    You use the same surgical code the surgeon is planning to perform. 56 is a modifier that is appended to surgical CPT codes.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6

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    Ah, ok! I see what you are saying. Thanks!

  7. #7
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    Debra - I have to respectfully disagree with your statement that this is not a consultation. If the surgeon is asking for an opinion from the PCP as to whether or not to clear the patient for surgery, then this is a consultation (request for an opinion). CMS has in the past clearly stated that this could be coded as a consultation. We have always coded this way provided the consultation requirements are met, and never been denied. You code the consult and dx codes :V72.8X, then the reason for the surgery, then comorbidities. However, now that Medicare has decided not to recognize consult codes, the visit for a Medicare patient would be an established visit 99212-99215. The PCP is not doing the pre-op management so the surgical code and modifier -56 would not be appropriate.
    Lisa Bledsoe, CPC, CPMA

  8. #8
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    I know we have always disagred on this and somewhere I have the position paper from CMS from the meeting where they made the decision to stop paying where this was discussed that these are not consults and should not have been coded this way. I will need to find this and will send to you but it will take me a bit. The surgeon is not asking for an opinion they are requestion a medical staus report. The surgeon will decide to take the patient to surgery or not. And when the PCP does this eval and gets all the necessary testing for this then this is the definition of preop management. IMO!

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
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    Debra - I would love to see that document. Not that it matters with CMS now, but for future reference with other carriers.
    Lisa Bledsoe, CPC, CPMA

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