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Preop clearance Help

  1. #1
    Default Preop clearance Help
    Medical Coding Books
    When coding a cardiology pre op clearance is there any specific criteria to be met or are we to follow the regular documentation guidelines, i.e. consult 99243 etc.? I have an issue where there is really no HPI. It only states insulin dependend diabetic, dyslipidemic, hypertensive & hypothyroidism. No chest pain,shortness of breath or syncope.

    All other areas met for exam and mdm.

    I also have one other question unrelated to pre op clearance. When performing comprehensive exam, documentation requirements state - perform all elements in at least 9 organ systems/areas but then it states you only have to document 2 elements from each?
    Seems strange to only have to document part of what is done?

    Thank you,
    Deb

  2. #2
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    Quote Originally Posted by CBC View Post
    When coding a cardiology pre op clearance is there any specific criteria to be met or are we to follow the regular documentation guidelines, i.e. consult 99243 etc.? I have an issue where there is really no HPI. It only states insulin dependend diabetic, dyslipidemic, hypertensive & hypothyroidism. No chest pain,shortness of breath or syncope.

    All other areas met for exam and mdm.

    I also have one other question unrelated to pre op clearance. When performing comprehensive exam, documentation requirements state - perform all elements in at least 9 organ systems/areas but then it states you only have to document 2 elements from each?
    Seems strange to only have to document part of what is done?

    Thank you,
    Deb
    A. You can't bill for pre-op clearance E/M - it's bundled into the surgery. Only the decision for surgery, or a significant and separately identifiable E/M service is reportable (Like an unrelated E/M, or an acute complication that suddenly came up before the surgery). Sorry...

    B. Under 1997 guidelines, for a comprehensive multi-system exam, you have to document a minimum of 18 bullets from at least 9 different organ systems. (2 bullets from each system). The doctor is supposed to perform all elements with a bullet within 9 different OS, but apparently he only has to write down the results from 2 of the bullets in each section. Yes, it is strange, but it's probably meant to avoid lots of redunant entries of "normal" findings in each system. I don't know how you'd prove that all of the elements were performed without documenting it, but I guess nobody's checking...kind of a stupid rule, really. Hope that helps!

  3. #3
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    Brandi, thank you very much for responding. I did not make myself very clear on the pre op exam. This is the cardiologist doing the pre op for lumbar surgery. Any advise?

  4. #4
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    Quote Originally Posted by CBC View Post
    Brandi, thank you very much for responding. I did not make myself very clear on the pre op exam. This is the cardiologist doing the pre op for lumbar surgery. Any advise?
    Check out this article:
    http://www.aafp.org/fpm/2004/0700/p16.html

    It'll depend largely on whether your patient has Medicare or not, and if they don't, whether the visit meets the requirements of a "consult" versus an outpatient exam.

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