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Thread: Annual PE/Pre-op Clearance

  1. #1

    Default Pre-op Clearance

    AAPC: Back to School
    I know this issue has been debated to death on these forums, but I have a question regarding pre-operative clearance.

    This patient came in for pre-op clearance for cataract surgery. We received a request from the surgeon for the clearance. This patient had not been seen since '09 and had not had an EKG since '05. We performed the pre-operative exam and performed the EKG. This patient has no chronic conditions that are listed, it was just a pre-operative clearance.

    How do we report this? Would we report a consult code (this is non-Medicare), an office/outpatient E/M code, or the surgery code with modifier 56 (as has been suggested on this forum before)? I see this as a screening since there are no chronic condtions involved, but I would like others opinions. Thanks.
    Last edited by dballard2004; 11-09-2010 at 12:25 PM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2


    Has anyone encountered this issue?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  3. #3
    Join Date
    Apr 2007
    Greeley, Colorado


    In my opinion this is a consultation. But as you say it has been debated to death. I don't consider this scenario as applicable to mod -56. You have a request for an opinion for surgical clearance and that is what is rendered. I have not encountered a clear cut example for the use of modifier -56, but it seems to me that it would be used if a surgeon provides office services prior to another surgeon doing the procedure for one reason or another (different hospital needed, the first surgeon didn't have that specific surgical skill, etc).
    Lisa Bledsoe, CPC, CPMA

  4. #4


    Thanks so much Lisa! I appreciate the insight!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

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