# Pre operative visits



## pscott

What is the correct way to code pre operative visits? I've read so much about it that I'm getting confused,
especially regarding decision for surgery visits and preoperative clearance visits.
Thanks!


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## AlaskanCoder

This depends totally on what you mean by "pre-operative visits". Are you talking about a visit to the surgeon (or the surgeon's NPP) or to a provider not involved with the surgery?  If the decision is made to do surgery during this visit, then you would code for the appropriate E&M and, if the surgery occurs on the same day or the following day, append modifier -57 to the E&M.  However, if the patient is coming in for a "history and physical" and to obtain consents and answer questions the patient may have - this encounter is not billable, as it is included in the reimbursement for the surgery.  In the RVUs for all surgeries with a 90-day global period, there is the work included for this encounter.  Technically, if this encounter happens 2 or more days before the surgery, you could bill it, but ethically you probably should not.  
There is no CPT code for a non-billable H&P encounter.  Some of my providers choose to use 99024 to track the frequency and the associated ICD-10CM codes for these non-billable services.  Others use a code they have created, such as Preop as a place holder for these encounters, when their EMR allows for this.  A few just don't enter them into the practice management system at all. 

A surgical clearance encounter would not be done by the surgeon.  A surgical clearance is where a specialist (usually) clears the patient for surgery.  For instance, if a patient with CHF is scheduled for a breast biopsy for a suspicious mass under general anesthesia, the surgeon and anesthesiologist may request clearance from the patient's cardiologist.  The cardiologist is not doing the surgery, therefore, the cardiologist will not be paid for any services included in the global package.  So, the cardiologist should code the pre-operative clearance encounter with the appropriate E&M code and follow the ICD-10-CM guidelines for the encounter.  These guidelines are in Section IV item M  "Patients receiving preoperative evaluations only. For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional code. Code also any findings related to the pre-op evaluation" So in the hypothetical case I mentioned the ICD10-CM codes would be Z01.810, N63, I50.9

Hope this helps, 
Karen Hill, CPC, CPB, CPMA, CPC-I
AHIMA Approved ICD-10-CM Trainer


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## Chelle-Lynn

You may want to review the attached link for the Medicare Learning Network for Global Services which discusses pre-operative services.  These are usually a very good resource for clear information when things start to get confusing.

In our office, the providers wanted to track how many pre-operative services they were doing that were inclusive to the surgery so we developed an internal "billing" code that allows us to track the services without actually billing a claim.

https://www.cms.gov/Outreach-and-Ed...oducts/downloads/GloballSurgery-ICN907166.pdf


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## pscott

Thanks to both of you for making it cleared!


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## graceroni13

We actually just had this issue pop up and I'm so happy I found this thread. One of our doctors said that Medicare wouldn't pay for pre-ops, so they were putting a code in that is $0 charge (99024/99025). So one of the coders brought it up to the PA that typically does this doctor's pre-op appointments. So the issue is that these pre-op visits are NOT the decision for surgery, but the PA is spending at least 20 minutes with these patients talking specifically about the surgery and giving them education on everything they need and answering their questions... I understand if they're wanting to include it in the payment for surgery, but is there ANY way we can charge for this ethically? And is this only for Medicare? Or do a lot of insurances follow this? I'm not trying to do anything wrong, but when these patients come in for their MRI results, that's when the doctor decides to proceed with surgery since he can see what's going on, but it's after that that this pre-op visit is happening where it's actually being thoroughly discussed and everything. We're putting the Z01.818 on the visit, but not mod 57 unless it's the day before or the day of surgery. I hadn't heard anything about this until now and want to fully understand what we can do to charge for it without getting in trouble of course, or if it's just a lost cause... I don't want to tell these doctors it's a lost cause and by the way hey, that full day of clinic your PA or NP is having is for free. You know? I've asked another coder and haven't heard back but I want to see what our options are of IF there are any.... I mean they should be paid for the amount of time and education they're giving I would think, but I'm not going to continue charging for these if it's flat out wrong. I mean does the time frame that this happens matter? This PA is doing them at least 3 days prior to the surgery... sometimes it's earlier.


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## CodingKing

It sounds like standard pre-op to me. Yes, patents have a lot of questions, but what they are discussing has no bearing as to whether the surgery is necessary or not. Now if the operation is cancelled, then it may become billable. They are not providing services free of charge. They are being paid for it through the surgery reimbursement. The surgical RVU includes a pre-op, interop and post-op component. The pre-op component is going to the visit you are describing by the PA

The timing of when it's performed doesn't determine if its billable or not. The decision for surgery can be made months in advance.If the visit is unrelated to the surgery, then it can be billed separately, if it's related then no. Global surgery is not a Medicare concept; it's a CPT concept, so it applies to every payer. 



graceroni13 said:


> We actually just had this issue pop up and I'm so happy I found this thread. One of our doctors said that Medicare wouldn't pay for pre-ops, so they were putting a code in that is $0 charge (99024/99025). So one of the coders brought it up to the PA that typically does this doctor's pre-op appointments. So the issue is that these pre-op visits are NOT the decision for surgery, but the PA is spending at least 20 minutes with these patients talking specifically about the surgery and giving them education on everything they need and answering their questions... I understand if they're wanting to include it in the payment for surgery, but is there ANY way we can charge for this ethically? And is this only for Medicare? Or do a lot of insurances follow this? I'm not trying to do anything wrong, but when these patients come in for their MRI results, that's when the doctor decides to proceed with surgery since he can see what's going on, but it's after that that this pre-op visit is happening where it's actually being thoroughly discussed and everything. We're putting the Z01.818 on the visit, but not mod 57 unless it's the day before or the day of surgery. I hadn't heard anything about this until now and want to fully understand what we can do to charge for it without getting in trouble of course, or if it's just a lost cause... I don't want to tell these doctors it's a lost cause and by the way hey, that full day of clinic your PA or NP is having is for free. You know?  I mean they should be paid for the amount of time and education they're giving I would think, but I'm not going to continue charging for these if it's flat out wrong. I mean does the time frame that this happens matter? This PA is doing them at least 3 days prior to the surgery... sometimes it's earlier.


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## candmwalter@gmail.com

*Pre Op Exam*

Hi can you include Chronic conditions in as a 3rd or 4th dx.  Example Pt present for preoperative cardiovascular exam.  He has a history of htn with moderate ckd.  He is scheduled for a total hip replacement for degenerative osteoarthritis of the right hip.  Can I code the Z code then the reason for surgery and include the HTNCKD and the stage or only report the z code the reason for surgery and any findings if found?
Thanks


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## bberube10

candmwalter@gmail.com said:


> Hi can you include Chronic conditions in as a 3rd or 4th dx.  Example Pt present for preoperative cardiovascular exam.  He has a history of htn with moderate ckd.  He is scheduled for a total hip replacement for degenerative osteoarthritis of the right hip.  Can I code the Z code then the reason for surgery and include the HTNCKD and the stage or only report the z code the reason for surgery and any findings if found?
> Thanks



You absolutely should code any significant condition or conditions the patient has as long as its documented in the providers notes.  The comorbidities enhance the level of risk for the surgery they are attending the pre-op visit for.   The hypertension and CKD would bump most pre-op visits to a level 5, as pre-ops are weighted heavily on the MDM, especially table of risk.


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## MelodyCPC

*pre op visit vs. surgery decision*



CodingKing said:


> It sounds like standard pre-op to me. Yes, patents have a lot of questions, but what they are discussing has no bearing as to whether the surgery is necessary or not. Now if the operation is cancelled, then it may become billable. They are not providing services free of charge. They are being paid for it through the surgery reimbursement. The surgical RVU includes a pre-op, interop and post-op component. The pre-op component is going to the visit you are describing by the PA
> 
> The timing of when it's performed doesn't determine if its billable or not. The decision for surgery can be made months in advance.If the visit is unrelated to the surgery, then it can be billed separately, if it's related then no. Global surgery is not a Medicare concept; it's a CPT concept, so it applies to every payer.



If the patient's questions during the pre-op visit involve changing the surgery (not removing ovaries during a hysterectomy versus removing them), does this make the visit billable based on the counseling time spent?


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