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Pre-Oprative Clearance

  1. #1
    South Salt Lake City
    Default Pre-Oprative Clearance
    Medical Coding Books
    I need help coding a visit by my Dr (not doing the surgery) that was requested by another Dr for the clearance. any Ideas? This is a first for this practice so I want to make sure I get the correct policy in place.
    Jody Thompson, CPC

  2. Default
    Make sure you got the 3 R's covered Request from the other provider (surgeon?), a written Response from your doctor (opinion) & the Return of the patient to the requesting physician. Depending on the type of pre-op exam done (cardio/pulm), the pre-op code (V72.x) is always the primary code, then you need to code the reason the pt is having the surgery & then code all the risk factor the pt has, like HTN, DM, etc...

    Last (but def not least), assign the E&M code, based on the pt status. I'm guessing he's an est. patient? We used to utilize the consultation codes, but this has changed (deleted), now it's either a new/est pt visit (99201-99214).

    Hope this helps

  3. #3
    Smile Pre-op
    I agree with AB98409 up until the mention of the consult codes. They have not been deleted. Medicare currently is the only contract carrierr that does not accept consults codes. 1. verify who the carrier is, 2. then check for the 3 R's. In addition to that, if the Payer is Medicare, they will accept consult codes when requested by a surgeon. see below:

    Medicare Carriers Manual 15506 states:
    “Pay for the appropriate consultation code for a pre-operative consultation for a new or established patient performed by any physician at the request of a surgeon, as long as all the requirements for billing the consultation codes are met.”

    Hope that helps.
    Last edited by sdunn; 03-25-2011 at 06:46 AM. Reason: added Information about consults codes per MCR manaual

  4. #4
    Fayetteville, NC
    I work for surgeons and we do similar exams on every now and then.
    But my claim scrubber will not allow me to bill a consult code to Medicare. I was under the impression that they did not pay consults at all anymore. Is there a special way you have to submit the claim?
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

  5. Default
    Okay guys, this is the 2nd time someone told me (on this site) that the consultation codes are well & alive...but we here, in WA, are not using them anymore! No insurance pays for them at all & we are not to use them...period! What's going??? Is WA the only place they did away with the Consult codes?

  6. #6
    Columbia, MO
    Okay first of all as of January 1 2010, CMS does not consider a consult a valid service to offer and therefore they will not pay for it. The person citing from the Medicare Manual needs to check the 2010 update as that section has been revised.
    Second, any carrier that wishes may adopt CMS policy for their own, and since CMS is considered the "gold standard" for health policies, most do adopt these. However it is always good to check first.
    Third, for a provider to perform a pre op exam on one of his patients at the request of another physician is not a consult and never was. This was one of the reasons cited by CMS as to why they no longer recognize consults. You cannot consult your own patient back for known problems. This is a medical evaluation the surgeon is wanting from the PCP. A pre op encounter is billed one of 2 ways
    the most correct yet controversial way is to bill using the surgical code the surgeon intends and append the 55 modifier. The other way is to use an office visit.
    Why is the 55 modifier the most correct? A surgical global consist of 3 identifiable segments, the pre op time, the surgical time and the post op time. Because at the request of the surgeon you are entering into the surgical global by performing the front end of the global for him ( the pre op) then you should bill for that portion of the global. The surgeon is not performing this part so should not be paid for this part, when you bill this way, using the 55 modifier, the surgeons reimbursement will be reduced by the amount you are paid. Now you see why it is not popular, at least among surgeons, but the reimbursement is 10% (15% with some payers) of the global allowable so for the PCP the reimbursement is very good.
    Last edited by mitchellde; 03-26-2011 at 07:38 AM.

    Debra A. Mitchell, MSPH, CPC-H

  7. Question Pre-op & Consultation codes
    Debra, thank you for clearing this up, for a minute I felt like the lone ranger out here
    Now, about the actual "Pre-op Consult", we are a Internal Med Clinic in a hospital setting & at times the surgeon of whatever department (GI/Plastic/General surgery, etc.), requests clearance from us for one of our patients (usually est.) due to health issues or meds the pt is taken that could possibly pose a risk during surgery. We are not participating in the surgery, we just give the "go ahead" to have the procedure or some other recommendation. Did I understand you correctly when you said that this would NOT be considered a pre-op consult (been using est/new E&M )

    R=request from another dept. (surgeon) for opinion/clearance
    R=responds by IMC provider (written clearance/recommendation)
    R=returned the pt to the requesting surgeon for tx


  8. #8
    Columbia, MO
    it is not a consult. it is a medical evaluation given at the request of the surgeon for the medical codition of the patient. The second R stands for render as in to render an opinion on something unknown. The patient and their medical conditions are well known to the PCP so the surgeon is asking for your to report the status of known medical issues. So you do not use consult codes. It is either an est patient visit level or the surgical code with the 56. The examination of the patient to determine medical staus prior to surgery is a pre op service that is accounted for in the surgical global. That is why if a surgeon requests that you now participate in the surgical global event you should bill with the 56 modifier to extract the preop reimbursemt from the global. I have tons of research on this and to be ones many commercial payer have this in their policies and and one even pays as much as 20% of the global allowable for the surgey. So the reimbursement is really very good. But remember the surgeons reimbursement will be reduced.

    Debra A. Mitchell, MSPH, CPC-H

  9. Thumbs up That's what we are doing!
    That's how I coded them out, as est. pt visits (99212-99215). We describe it differently, but in the end it's the same process, same codes. I'm relieved to know that I was not imagining that the consult E&M codes are basically a thing of the past

    Thanks Debra!

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