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Cardiology Coding Alert

Medicare Carriers Instructed To Accept V Codes for Pre-Op Consults

Published on Sun Jul 01, 2001

The Centers for Medicare & Medicaid Services (CMS, formerly HCFA) has instructed all local Medicare carriers to accept V codes for preoperative clearance. Until now, many carriers have routinely denied preoperative consults by cardiologists and other specialists if preoperative clearance V codes were used.

The announcement singles out four preoperative clearance ICD-9 codes, including:
 
  • V72.81 -- preoperative cardiovascular examination
     
  • V72.82 -- ... respiratory examination
     
  • V72.83 -- other specified preoperative examination
     
  • V72.84 -- preoperative examination, unspecified

    • The clarification, which revises section 15047 of the Medicare Carriers Manual (MCM), states that V72.81-V72.84 should be used to show medical necessity for preoperative clearance evaluations.

    Medicare transmittal R1707-B3, issued May 31, instructs carriers to "delete any processing edits that deny claims or identify for manual review ICD codes V72.81 through V72.84." However, "claims containing these codes are subject to medical necessity determinations as described in MCM section 15047H."

    According to the new language in section 15047C, Medicare will pay for all medically necessary preoperative clearances, such as those that involve "evaluating a patient's risk of perioperative complications and to optimize perioperative care."

    Local Medicare carriers retain the discretion to determine the medical necessity for a preoperative clearance, CMS says.

    "Medicare probably issued this to set the carriers straight," says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. "Many carriers routinely denied these services on first submission when the V codes were correctly used as a primary diagnosis."

    After the denial was appealed and the claim was reviewed manually, it was usually paid, Callaway says. But, she notes, not all such denials are appealed. The new revision should result in far fewer denials when cardiologists use a V code as the primary diagnosis.

    According to the revised language in section 15047G, "All claims for preoperative medical examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 through V72.84). Additionally, the appropriate ICD-9 code for the condition(s) that prompted surgery must also be documented on the claim. Other diagnoses and conditions affecting the patient [presumably, the condition that prompted the surgeon to send the patient to the cardiologist for a preoperative clearance] should also be documented on the claim, if appropriate."

    The transmittal further specifies, "The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (i.e., V72.81 through V72.84)."

    The clarification also means that cardiology coders can use the appropriate ICD-9 code to get paid for preoperative consults, Callaway says. She notes that in states where local Medicare carriers routinely deny consult claims with preoperative clearance V codes as the primary diagnosis, some cardiologists would use the condition (coronary artery disease or tachycardia, for example) as the primary diagnosis to get paid.

    Technically speaking, this was incorrect ICD-9 coding because the patient did not see the cardiologist for problems related to the condition, but rather as a preoperative clearance.

    The call to include the diagnosis that prompts the surgery may also reduce the number of denied claims (and manual reviews), says Arlene Morrow, CPC, a coding and reimbursement specialist in Tampa, Fla.

    "When, for example, the orthopedist sends a patient to the cardiologist to evaluate the patient's cardiac status before a total hip replacement, the UPIN number for the requesting physician [the orthopedist] needs to match an orthopedic diagnosis [i.e., the diagnosis that prompted the decision to perform a hip replacement]," Morrow says. The diagnosis that prompted the surgeon to request the preoperative clearance should also be included because it provides medical necessity and explains why, for example, V72.81, as opposed to V72.84, was used.

    Medicare carriers can read only one diagnosis per line item (service or procedure) on an electronic claim, and even when the claim is adjudicated manually the reviewer cannot see the additional diagnoses until and unless a paper claim is provided.

    The cardiologist is also likely to perform diagnostic tests to evaluate the risk to the patient. Typically, an electrocardiograph (93000 or 93010) is performed, and stress echocardiography or nuclear scans may also be done -- all of which can be billed separately. When this is the case, one additional diagnosis can be submitted electronically for every additional service or procedure reported.

    Follow Consultation Criteria

    The key factors that determine whether a preoperative consult should be billed, Morrow says, are much the same as for any other consult: Follow all the consultation criteria and document that the consult was medically necessary.

    The criteria for distinguishing a consult from another E/M service, found in section 15506 of the MCM, are:

    1. [The consultation] is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation).

    2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record.

    3. After the consultation is provided, the consultant prepares a written report of his or her findings, which is provided to the referring physician.

    Although there has been much controversy about what constitutes a "transfer of care," this issue has less of an effect on preoperative clearances because care is typically returned to the surgeon.

    For example, a general surgeon schedules a patient with a history of congestive heart failure for a colectomy. The surgeon wants the patient evaluated by a cardiologist, who will render an opinion on whether the patient is a suitable surgical candidate. After evaluating the patient and performing diagnostic tests, the cardiologist clears the patient for surgery.

    Even if the preoperative consultation leads to the determination that the patient should not undergo the surgery, a consult can still be billed as long as the request for an opinion was made and a written report of findings was provided to the requesting physician.

    For instance, an elderly patient has a large abdominal aortic aneurysm. The patient also has other severe health problems, such as chronic congestive heart failure and chronic obstructive pulmonary disease. After examining the patient, the cardiologist advises against surgery.

    The cardiologist can still bill a consult if the surgeon's request for an opinion or advice is in writing and he or she provides the surgeon with a written report (in the hospital, an entry in the patient's medical record is sufficient).

    "The requesting surgeon needs to set it up appropriately," Morrow says. "The written request should include words to the effect, 'I am asking for your opinion on whether patient X is a suitable candidate for surgery.' The cardiologist needs to explain in his or her documentation, 'I am seeing patient X at the request of general surgeon Y, to evaluate the patient's congestive heart failure and fitness for surgery.' If all this is done and the report is sent back to the surgeon, it qualifies as a consultation."

    Use Terminology Precisely

    Morrow also recommends that when writing reports, cardiologists use the term "requesting surgeon" rather than "referring surgeon" because in the past some carriers have denied consultation claims, incorrectly assuming that a referral implied a transfer of care, even though MCM section 15506 uses the term several times.

    Some cardiologists believe they cannot bill a preoperative consult for their own patients. This is incorrect, Morrow says. A preoperative consultation (or any other consult, for that matter) may be billed for both new and established patients as long as an opinion is rendered and the other consultation criteria have been met.

    A consult should not be billed if:

  • Any of the criteria are not met or documented. A visit (office or inpatient) should be billed instead.
  • The history and physical is performed by the cardiologist because the surgeon does not want to perform the preoperative evaluation included in the surgery's global package.

    • Note: If the cardiologist provides a preoperative consultation and then sees the patient postoperatively, bill those visits with the appropriate-level established patient or subsequent inpatient care codes, according to section 15506F of the MCM.

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