Use Correct Diagnosis Codes To Bill Pre-op Clearance
Published on Tue Feb 01, 2000
Code V72.81 (preoperative cardiovascular examination) has been the textbook ICD-9 code to use when billing for tests and/or examinations performed on patients about to undergo surgery. But increasingly, Medicare carriers are denying such claims if V72.81 is the only diagnosis or the first one listed on the HCFA 1500 claim form. Coders should use the diagnosis code that describes why the cardiologist was asked to see the patient.
Typically, what happens is that other physicians send patients with a history of heart problems who are about to have surgery to a cardiologist for an exam and tests. But many Medicare carriers now view such preoperative clearances as screenings, for which it does not pay. And an increasing number of carriers will not pay for it unless there is a payable diagnosis or symptom. Many hospitals require clearance, however, citing good medical practice and liability concerns.
As a result, says Terry Fletcher, BS, CPC, a coding and reimbursement specialist in Laguna Beach, Calif., some carriers now only cover V72.81 for the exam, not for the tests, and sometimes, depending on the carrier, not even for the exam. A lot of offices are having problems getting reimbursed for the tests, and sometimes even for the exam, when they use V72.81 as their only diagnosis code. Another option is to code the surgical diagnosis, but if the patient is having gallbladder surgery, for example, and requires car-diac clearance, coding 574.00 (calculus of gallbladder with acute cholecystitis, without mention of obstruction) is not a covered diagnosis for labs or EKGs, only for the exam.
List Diagnosis First
What Medicare wants is a diagnostic reason for the pre-op clearance, such as previous heart surgery, says Denise Reckers, a coder with Cardiology Consultants, an 11-member cardiology practice in Abilene, Texas. For Medicare to cover it, you need a sign or symptom code or a diagnosis as to why the patient requires pre-op clearance, Reckers explains.
And that diagnosis should be listed first on the HCFA claim form, ahead of V72.81, Fletcher says. Because many carriers computers accept only one diagnosis code, V72.81 should be added as a second diagnosis code, particularly for lab tests, Fletcher notes.
What has been helpful is that offices have been coding V72.81 for exam portion only and including a comprehensive history on the patient to verify a covered diagnosis such as family history, heart disease or hypertension, which would cover labs, EKGs, etc., Fletcher says, as Medicares screening guidelines apply more for tests than other services.
Even if an established patient is coming in for the clearance, offices still have to go back and look at the patients history, Fletcher notes. Quite often, lab services will be paid by signs and symptoms [...]
