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Pre-op Exam Coding

  1. #1
    Default Pre-op Exam Coding
    Medical Coding Books
    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!

  2. #2
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    The absolute correct way to do this is the use of the surgery code with the 56 modifier but you must have proof in the chart that this patient was referred for this preop by the surgeon. If not referred by the surgeon then it is an office visit level. If you look in your carriers guide there should be something regarding the use of this modifier. BCBS states they will reimburse 15% of the surgical allowable for the use of this modifier.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    I dont agree with billing this with a 56 modifier, a 56 is for preoperative management. The pcp is not doing the preop management, they are simply doing the clearance. The surgeon is doing the preop management by evaluating the patient's surgical problem and advising them on the risks and benefits of surgery.

  4. #4
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    The surgeon ordinarily provides that service in the first encounter and bills an office encounter usually with a 57 modifier, but then send the patient to the PCP for preop, that then is the preoperative management. To check the patient over prior to a surgery at the request of the surgeon.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    Concord, NC or Rochester, NY
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    It sounds like this is a pre-operative clearance which is billed with a consultation code. If the carrier does not accept consult codes then move to new/existing patient codes

  6. #6
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    We do many pre-ops in the office and it is a consultation depending on the insurance as some do not pay for them,otherwise it is an E/M level, I don't see how you can bill for the surgical procedure that is being done by another physcian, your provider is not doing that procedure and cannot bill for it.

  7. #7
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    Pre op is not a consult if this is your patient. The surgeon is not asking you for an opinion, they are wanting a report of the patient's medical condition at this time. You are not making a decision about surgery. This was one of the issues cited by CMS as the reason they decided to disallow consultations. You are not billing for the surgery you are billing for the preoperative component. If the surgeon requests that you perform the preoperative examination then they are asking you to provide the preoperative part of the surgery. The surgical global consists of 3 parts, the preop, the surgery, and the post op. These can each be split out for separate reimbursement using modifiers 54,55,56. If the surgeon is telling your physician to perform the pre operative exam then obviously the surgeon is not going to do it so why should the surgeon get that part of the global fee. That is why the AMA created these modifiers and they attach to the surgical code.

    Debra A. Mitchell, MSPH, CPC-H

  8. #8
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    I just thought I would add this from the Blue Cross Manual:
    · Modifier 56 is reported when one physician performed the preoperative care and
    evaluation and another physician performed the surgical procedure. Modifier 56 is
    appended to the surgical code. The physician is paid a portion of the global
    package.
    · Modifiers 56 must only be appended to the surgical procedure codes.
    · Procedure codes with modifier 56 appended will price at 15% of the allowable
    charge.

    There are many others and the percentage is different but somewhere between 10 to 15% of the surgical allowable.

    Debra A. Mitchell, MSPH, CPC-H

  9. Default
    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.

  10. #10
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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.
    This is true. The OB/Gyn docs I worked for did their own pre-op visit for the surgery, but sometimes especially on older patients, they would request a pre-op clearance from the PCP. This is not a pre-op visit because it is unrelated to the reason for the surgery. Frequently the PCP is checking the cardio or respiratory status of the patient to see if they can tolerate anesthesia and surgery. The PCP bills an E/M visit with diagnosis code from V72.8x series where there are specific pre-procedureal diagnosis codes.

    The use of the surgery code with the 56 modifier is intended to be used when one provider provides ALL the pre-op services, which would include the decision for surgery.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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