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Pre-op Exam Coding

  1. #21
    Location
    Lebanon, New Hampshire
    Posts
    31
    Default
    Medical Coding Books
    This is the information I've handed out to my family practitioners when they're performing a pre-op H&P....it may contain more than you were looking for, but just disregard what you don't want.

    Rita Conley, CPC, CEMC

    PREOPERATIVE CONSULTS: There seems to have been confusion of late surrounding pre-op H&Ps and when it is, and is not, appropriate to bill for a consult vs. established/new patient office visit. Please see below for guidance.

    BILL A CONSULT when the surgeon requests a consult for pre-op clearance due to a patient's chronic underlying medical conditions; this visit would qualify for a consult, as the medical necessity is supported by the potential effect the underlying condition(s) could have upon the surgery.

    DO NOT BILL A PREOP CONSULT when a patient comes to the office with a surgical pre-op form and is seen for a pre-op H&P (without a specific consult request from the surgeon) -- this visit would qualify for a new or established patient E/M (evaluation and management).

    DO NOT BILL A PREOP CONSULT if a surgeon requests a consult for a pre-op clearance simply because

    (a) he/she does not perform them in the office, AND
    (b) the patient has no chronic underlying medical condition for which surgical clearance is necessary.

    This visit would qualify for a new/established patient E/M only

    RATIONALE:
    One cannot assume a consult....the surgeon needs to request it and document the request in his/her notes/orders, etc.

    Remember the three R's--Request, Render, Report--that are required in order to bill a consult.

    Prevent med E/Ms cannot be utilized for pre-op H&Ps....the visit would be billed with either a new/established or consult code.

    Selecting your level of E/M based on key components vs. time depends on how the visit evolves. To select the appropriate level of service, all three key components (history, physical examination, medical decision making) must be met, or the code may be reported based on time if more than 50% of the total face-to-face service is spent in counseling or coordination of care.

    Remember also when billing for pre-op H&Ps, assign diagnoses as follows:
    1. V72.83 (pre-procedural general PE)
    2. Dx best describing reason for surgery.
    3. Co-morbid conditions that may have an impact on surgery.

  2. #22
    Location
    Chesapeake, Virginia
    Posts
    16
    Default
    So to add more confusion to the mix, does anyone know the proper way to code this scenario? Our Hospitalist is asked to evaluate a patient in the ER for admission. He writes the order for admission and asks a specialist- let's say Ortho to evaluate let's say a hip fracture. Ortho decides the patient needs surgery and asks the Hospitalist to do pre-op clearance. I think the Hospitalist should bill an initial hospital visit on day one, and a subsequent for the pre-op clearance if on a separate dos. But what if this is all done on the same dos, would it be appropriate to bill the consult code in place of the initial visit? Of course for those carriers who aren't allowing consult codes it would be the same code either way.

    Thanks.

  3. Question pre-op
    I currently work for a family practice and understand the need for clarity on pre-op coding. I have always coded with a consultation code with valid request from surgeon and use v72.8x dx codes. No modifiers unless add'l problems not related to the consult-I'd add an ov with mod 25. I am totally doing this wrong right? HELP

  4. Default Pre-op's
    In my practice we make sure if we are billing Medicare we will bill a regular office visit, new or established since medicare do not pay for consultations. For commercial Insurances if the provider is assesing chronic conditions we bill a Consultation code as long as the report meets all requirements for this (RRR). No modifiers appended unless we do an EKG. In this case we append modifier 25. And the ICD-9 code tu use is the
    V72.8__ .

  5. #25
    Default Celestine Lewis,CPC
    I am a Radiology Coder, can anyone give me a Dx code for Ventricular Reflux of the Tracer. i couldn't find anything except the reflux code.

    thanks!

  6. Default
    A pre-op visit requires medical necessity in order for the provider to bill an E/M code (99212-99205). CMS is very clear on this, and MAC's like Noridian, have an LCD clearly spelling out the requirements. The visit must be scheduled to evaluate the risk factors for a surgery, ie...COPD, smoking, HTN and then provide clearance for identified risk factor(s). Medical necessity is not met when a surgeon requests routine pre op testing such as labs, xrays, ekgs. This preop testing is part of the surgeon's global payment and must not be referred to a PCP. The patient should be sent to the hospital for this routine work. Surgeons need to be educated as well because they are used to delegating this 'routine' work onto the PCP and, therefore, balk when they are told this is inappropriate.

    Lillian
    CPC, CPMA
    Last edited by loptas; 11-15-2011 at 12:52 PM. Reason: pre-op screening

  7. #27
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by shirleyharris View Post
    So to add more confusion to the mix, does anyone know the proper way to code this scenario? Our Hospitalist is asked to evaluate a patient in the ER for admission. He writes the order for admission and asks a specialist- let's say Ortho to evaluate let's say a hip fracture. Ortho decides the patient needs surgery and asks the Hospitalist to do pre-op clearance. I think the Hospitalist should bill an initial hospital visit on day one, and a subsequent for the pre-op clearance if on a separate dos. But what if this is all done on the same dos, would it be appropriate to bill the consult code in place of the initial visit? Of course for those carriers who aren't allowing consult codes it would be the same code either way.

    Thanks.
    In this scenario, the hospitalist is doing an H&P to admit the patient anyway, he should not get additional for preop clearance. Hospitalist should bill appropriate codes for admitting and following the patient.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  8. #28
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default
    Absolutely disagree - the PCP is not performing the pre-op care as they are only supplying information requested by the surgeon. The surgeon is asking for an opinion as to whether the patient is eligible for surgery based on their ability to withstand the surgery. Pre-op management would be if one physician was caring for the patient and the decision was to allow another surgeon to perform the surgery.

  9. Default Pre-Op Exam
    In our case (ophthalmology), I am not sure how the primary care doctor could examine the eyes, perform a slit exam, determine if there is a catarat, determine the type, determine if meets the medicaly necessity criteria, perform the test for lens measurement, etc. When we have done all of these things and determined that, yes, this patient meets all medical requirements for the surgery, we then post the surgery at some time in the future, usualy 3 to 4 weeks later. This completes the pre-op exam. Then before the surgery, the surgical facility requires that the patient be"cleared" for surgery, i.e.: no heart or chest problems, not blood sugar problems, etc.


    If the patient has been in to see the primary care physician, then the only thing needed is a brief form detailing the results of that visit. If not, then a brief exam is required to determine clearance for surgery.

    Hope this helps.

    Bobbie Sox, Practice Administrator
    The Eye Center PA
    Columbia SC

  10. #30
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default
    The ophthalmologist may do the workup from the eye perspective. However, if they are concerned about the patient being able to tolerate the procedure (anesthesia, etc), they may ask a PCP for surgical clearance. At this point the PCP has been asked for their opinion and would bill a consult unless the insurance carrier does not accept consults at which point they would then bill a new/established patient.

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