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Pre-op Exam Coding

  1. #11
    Location
    Milwaukee WI
    Posts
    4,466
    Default And you are NOT coding for this?
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    Quote Originally Posted by penguins11 View Post
    I still totally disagree, the pcp is not providing the preop care. We sometimes see a patient 5 or 6 times before deciding on surgery, the dr may order pt, epidurals, etc before deciding on surgery, the pcp is not treating the patient for the operative problem, only doing the clearance which is not preoperative management. Making sure a patient can make it through anesthesia by doing a cardiac clearance is not preoperative management of a lumbar disc herniation. Clearance may be required from 3 different physicians, the pcp for general, pulmonologist for lungs and cardiologist. The are not treating the patient for the operative problem or doing any type of management, they are only doing the clearance. An example, to me of using the 56 modifier would be if a patient went to a neurosurgeon in another state for the conservative managemtn and had the surgery done by our neurosurgeon. Our neurosurgeon did the surgery only but non of the preop management.
    Penquins ... the global surgery package INCLUDES the initial hospital visit or pre-op exam. I realize that your surgeons have done considerable pre-operative work before deciding to do surgery (or the extent of the surgery), however, all that was coded and paid separately.

    When I state that the PCP should code the surgery with a -56 modifier it is because the SURGEON is NOT doing the hospital H&P at all, but leaving that entire piece to the PCP. (I know of one ortho surgeon who has bragged that he doesn't even OWN a stethescope.)

    Certainly if your surgeon is requesting a consultation (i.e. advice/opinion on co-morbidities) for issues s/he does not typically deal with, it's appropriate for the consulting physician to code the E/M as per documentation and guidelines (consult codes are still covered by most payers, just not Medicare or other government payers).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 11-04-2011 at 10:16 AM.

  2. Default
    I never indicated that we bill for the preop exam, we bill for all of the office visits up to the preop exam, The preop is a $0 charge. Also, the pcp's never do the H&P's for our patients. If we admit to the hospital for a surgery our surgeon's do the H&P. The pcp is not the admitting physician, our surgeon is the admitting. I have never heard of the pcp dictating the H&P and doing the admit for a planned surgery. All of the specialists admitting a patient for a planned surgery in our area dictate their own H&P's, not the pcp.

  3. #13
    Default Specialists doing and H&P, that is unheard of in my area...
    The specialists in my area do not admit patients at all, they make the primary admit them and stay on the case so all they have to do is their surgical notes and follow up. The primary providers has to do the H&P and the discharge. But they do not coordinate billing with the primary offices so they can bill appropriately with the surgical code.

    This is wrong. This needs to change. It is a culture issue that I have been dealing with for years.

    There are times when the specialist truly does consult a primary for clearance. In those cases the consult code or other E/M would be appropriate. In those cases there will be an actual reason for the visit not just "preop clearance". They should be asking for "cardiac clearance" and the surgery not even scheduled until the clearance is received. The majority of the time though, the specialists has no reason for sending them to their primary othere than there has to be an H&P on the chart. They plan to do the surgery no matter what the other provider says.

    Just my 2 cents,

    Laura, CPC, CPMA, CEMC

  4. #14
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by penguins11 View Post
    I never indicated that we bill for the preop exam, we bill for all of the office visits up to the preop exam, The preop is a $0 charge. Also, the pcp's never do the H&P's for our patients. If we admit to the hospital for a surgery our surgeon's do the H&P. The pcp is not the admitting physician, our surgeon is the admitting. I have never heard of the pcp dictating the H&P and doing the admit for a planned surgery. All of the specialists admitting a patient for a planned surgery in our area dictate their own H&P's, not the pcp.
    I agree that in this situation the PCP is not dictating an H&P for admit, they are doing an exam and reporting to the specialist if the patient is, or is not, healthy enough for surgery and anesthesia. This is a preop clearance that is separate from the acutal preop visit with the specialist.

    If, however, there is a situation where a specialist has a PCP doing the preop work, and the PCP dictates the H&P that is used to admit the patient to the hospital and the specialist does not see the patient for a preop visit, then perhaps the surgery code with the 56 modifier is more accurately describing the work that was done. That is not the way any specialist I have worked with does things, but it is certainly a possible scenario.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  5. Default
    I totally agree that you should use an E&M code for the pre op exam.

  6. Default
    Thanks, Arlene. I think you had it right the first time. Our PCP's do pre-op clearances and bill E/M visits. I've never seen Mod 56 used by any of our practices (FP or specialty) in any situation.

  7. Default
    Penguins I totally agree!

  8. #18
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default
    This really is quite simple:

    The PCP is being asked for an opinion on the ability of the patient to have surgery - hence pre-op clearance.

    They are not performing pre-operative management.

    they are providing a report to clear the patient based on the surgeon asking for the clearance.

    Therefore you would bill a Consultation Code and if the insurance carrier does not accept these then you would bill a new/established patient. If the doctor is the PCP of the patient - the MD can still bill a consultation code.

    Cannot be any clearer that this

    Mike

  9. #19
    Default
    Quote Originally Posted by kcaskey03 View Post
    I have a question on how to correctly code a pre-op exam. I work at a family practice office and we occasionally do pre-op exams for surgeons that request the preop exam. Do we code an E&M level (9921X) or do I need to get the surgical code that the surgeon will be using and bill the surgical CPT code with a modifer 56 ? Ive tried to do some research on this and I've heard people doing it both ways. If the answer is to use the surgical CPT code, what if the surgery changes into a more extensive surgery... this may change the CPT code, does that affect anything? I would appreciate anyones help!
    The proper way for a family physician/primary care physician to bill this surgical clearance is with an E/M code and ICD9 code V72.84. If the physician also does an EKG, you would bill the appropriate EKG CPT with ICD9 V72.81.
    Modifier 56 is intended for use when a surgeon does all the workup for the surgery, but a different surgeon actually does the procedure.

  10. Default Preop exams -
    For those insurers that still recognize consultations we apply the following: Preoperative consultations are payable for new or established patients performed by any physician or NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening.
    Medical preoperative exams and preoperative diagnostic tests are payable if they are medically necessary and meet the documentation requirements of the service billed.
    All preoperative claims must be accompanied by the appropriate ICD-9 code for Preoperative examination (V72.81-V72.84). Additionally, report DX code for the condition(s) that prompted the surgery must also be reported. Other DX and conditions affecting the patient should also be reported.
    A physician or NPP cannot bill either an E/M or consultation for preop visit if the patient doesn't have any known underlying conditions. The E/M or consultation in the absence of signs or symptoms of a disease or illness would be screening and not covered.Note: For insurers that don't recognzie consultations - we report a new or established office visit to report a pre-op clearance visit and apply the preop exam dx and reason for the surgery and other dx that are relevant.


    NHIC E/M GL 2011 Medicare Manual

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