# Table of Risk - If a physician is seeing a patient



## Vicki

If a physician is seeing a patient for a pre-operative clearance and the patient has many chronic illnesses, all of which are well controlled, would the patient be considered high risk for this physician?

I know the patient is at high risk for the surgery but the pre-op physician is not performing the surgery just clearing the patient for surgery.

Thank you for your help.

Vicki


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## charlottetweed

2 or more stable chronic illness are moderate level risk.  As you pointed out the patient is NOT having surgery from your physician.  The patient is there to be checked for his chronic illness.  
Hope this helps.


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## Vicki

He can easily meet a moderate level of risk but this doctor is charging most people a 99205. He states that these patients are high risk for surgical complications due to their medical conditions which is true, but I don't think they meet a high level of risk for the pre-op clearance. He always has enough diagnoses to meet a high level MDM, sometimes he can reach a 99205 with the amount of data reviewed but not always. 

Am I correct in separating out the risk for him vs the surgeon? The surgery is high risk but the pre-op clearance is not putting the patient at risk. 

Thanks for your hel.p.


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## sparkles1077

What specialty is your physician and what specialty is the surgeon?

If it is a high risk surgery, your physician probably has to complete a comprehensive history and exam.  If all elements for these are met,  I would go with the physician for level of risk.  Time documentation would also be supportive in this situation.

Diana, CPC
Auditor at Private


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## btadlock1

Vicki said:


> If a physician is seeing a patient for a pre-operative clearance and the patient has many chronic illnesses, all of which are well controlled, would the patient be considered high risk for this physician?
> 
> I know the patient is at high risk for the surgery but the pre-op physician is not performing the surgery just clearing the patient for surgery.
> 
> Thank you for your help.
> 
> Vicki



I don't think so - the key is "well-controlled". When you hear "high risk", think imminent threat of loss of life or bodily function. As long as the conditions are under control (and if there's no indication that the patient has experienced any recent symptomatic-episodes), I probably wouldn't go with the highest possible E/M level. It really does depend on the documentation, though - what the conditions are, and what the surgery is for. It's very hard to determine medical necessity without those details. Hope that's _some_ help!  Happy Easter!


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## btadlock1

Vicki said:


> He can easily meet a moderate level of risk but this doctor is charging most people a 99205. He states that these patients are high risk for surgical complications due to their medical conditions which is true, but I don't think they meet a high level of risk for the pre-op clearance. He always has enough diagnoses to meet a high level MDM, sometimes he can reach a 99205 with the amount of data reviewed but not always.
> 
> Am I correct in separating out the risk for him vs the surgeon? The surgery is high risk but the pre-op clearance is not putting the patient at risk.
> 
> Thanks for your hel.p.



Just curious - why is your doctor doing the pre-op clearance in the first place? You mentioned him billing 99205, which is a new patient code - is there any particular reason why your physician is doing the pre-op clearance instead of the patient's regular physician, who should already be familiar with their health history? It just seems odd to have that done by a doctor who has nothing to do with the patient's ongoing care, or the actual surgery...Forgive my ignorance, but I honestly don't know - is that common?

If it was requested by the surgeon, and the patient is non-Medicare, you might be able to bill a consult code instead of an outpatient E/M...Just a thought...


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## LLovett

*Pre-op is included in the surgical package, shouldn't be an E/M at all*

This should really be billed as the surgical procedure code with the pre-op care only modifier, 56.

Laura, CPC , CPMA, CEMC


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## sparkles1077

We often have specialty providers doing preop clearance.  For example, a cardiologist may need to clear a patient for neurosurgery or dental.  They bill E and M codes for these visits - they are not part of the global because they are a different physician and specialty


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## Vicki

In my experience, this is common. In this case it is an internist clearing the patient for orthopedic surgery. The reason that the patient's primary care provider is not performing the clearance is that the clearing physician will perform follow up care while the patient is in the hospital following surgery. He will follow the medical issues during the post op period.


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## colorectal surgeon

A high level of risk is major surgery with risk factors? What does that mean exactly?  I believe it is supposed to be patient risk factors, not surgery risk factors? 

I have heard before that the diagnosis must pertain to that specialty? So I am not able to list hypertension, osteoarthritis and get credit for these since I'm not managing them? However, when evaluating a patient for surgery, these play into the risk in my mind. But they may or may not when I'm treating something minor, hemorrhoids or other anorectal problems in my specialty.  

Any comments?


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## mitchellde

sparkles1077 said:


> We often have specialty providers doing preop clearance.  For example, a cardiologist may need to clear a patient for neurosurgery or dental.  They bill E and M codes for these visits - they are not part of the global because they are a different physician and specialty



Different physician and different specialty does not mean they are not part of the surgical global.  They are participating in a defined portion of a global event, the pre operative  portion.  Which is why there is a modifier for this portion, the 56.  That modifier does append to the surgical code as Laura states for any physician that is performing the preoperative portion of a surgery at the request of the surgeon.  If you do not perform the total compliment of the pre op then you can append a 52 as well to show you did not perform the complete pre op.
Many payers will recognize this modifier and the reimbursement is anywhere from 10 to up to 20 percent of the global, AND the surgeon's global reimbursement will be reduced by this amount.


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## jbrashear

*Table of Risk*



colorectal surgeon said:


> A high level of risk is major surgery with risk factors? What does that mean exactly?  I believe it is supposed to be patient risk factors, not surgery risk factors?
> 
> I have heard before that the diagnosis must pertain to that specialty? So I am not able to list hypertension, osteoarthritis and get credit for these since I'm not managing them? However, when evaluating a patient for surgery, these play into the risk in my mind. But they may or may not when I'm treating something minor, hemorrhoids or other anorectal problems in my specialty.
> 
> Any comments?



It is supposed to be patient risk factors and not surgery risk factors. And I would agree that if you are treating minor complaints such as hemorrhoids or other anorectal problems, you should not code hypertension, etc. Those types of conditions would not increase patient risk for loss of life/bodily function in such unrelated minor problems. But if you are doing a pre-op evaluation, hypertension, diabetes, etc. are all risk factors for the patient and should be documented. Wouldn't it be neglectful to do otherwise?

Just thinking...

Janice Brashear, CPC


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## jbrashear

*Global period*



mitchellde said:


> Different physician and different specialty does not mean they are not part of the surgical global.  They are participating in a defined portion of a global event, the pre operative  portion.  Which is why there is a modifier for this portion, the 56.  That modifier does append to the surgical code as Laura states for any physician that is performing the preoperative portion of a surgery at the request of the surgeon.  If you do not perform the total compliment of the pre op then you can append a 52 as well to show you did not perform the complete pre op.
> Many payers will recognize this modifier and the reimbursement is anywhere from 10 to up to 20 percent of the global, AND the surgeon's global reimbursement will be reduced by this amount.



The 2011 AMA CPT(r), p. 52, defines the E&M portion of the surgical package as follows:

Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical).

So, if a provider, regardless of specialty, performed a pre-operative examination for clearance of the patient two days or one week prior to the surgery, wouldn't that exclude that service from the surgical package? And wouldn't the provider use a regular E/M (99201-99215) or a consultation code (99241-99245), if services were requested by the surgeon?

Janice Brashear, CPC


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## sparkles1077

jbrashear said:


> The 2011 AMA CPT(r), p. 52, defines the E&M portion of the surgical package as follows:
> 
> Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical).
> 
> So, if a provider, regardless of specialty, performed a pre-operative examination for clearance of the patient two days or one week prior to the surgery, wouldn't that exclude that service from the surgical package? And wouldn't the provider use a regular E/M (99201-99215) or a consultation code (99241-99245), if services were requested by the surgeon?
> 
> Janice Brashear, CPC



I would agree Janice.  The surgeon would still complete the preop history and physical exam.  These services are clearance for surgery requested by the surgeon.  Perhaps the verbiage "preoperative" is confusing.  The surgeon is actually requesting a consult from the specialist.  We do not add the modifier 54 in these situations.

Diana, CPC
Auditor at Private


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