# Preop clearance Help



## CBC (Mar 24, 2011)

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


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## btadlock1 (Mar 24, 2011)

CBC said:


> 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.
> 
> ...



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!


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## CBC (Mar 24, 2011)

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?


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## btadlock1 (Mar 24, 2011)

CBC said:


> 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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