EM Coding Alert

Note the pre-op clearance is different from an H&P.

Many providers, both primary care and specialists alike, get requests from other providers asking them to clear a patient for surgery. If your physician performs this type of service, be careful how you code the encounter. If you don’t choose correctly, you might only bring in a portion of the reimbursement your provider deserves, or worse, your claim might come back unpaid.

Take a look at these three tips to keep your pre-op clearance exam coding on the up and up.

Consider a Consultation Code

Before you bill, check to see that there is a request from a surgeon and medical necessity for a pre-op consultation, says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J. in her audioconference E&M Documentation: Train the Trainer from The Coding Institute’s affiliate AudioEducator.com.

“This is not just a relatively healthy person,” she explains. “This is a patient that needs a respiratory clearance, or a diabetic patient who needs clearance based on their insulin intake and things like that, or a patient that needs a cardiac clearance. There has to be medical necessity.”

When your physician is asked by another provider to clear a patient for surgery, look first at the place of service, then the payer. You can report an evaluation and management code, but which code you’ll use depends on whether the encounter takes place in the office or hospital and which payer you are billing.

Start by looking at the consultation codes (99241-99245, Office consultation for a new or established patient, … or 99251-99255, Inpatient consultation for a new or established patient ...) for payers not following Medicare guidelines if the documentation meets the criteria for consultation coding.

If the payer, such as Medicare, does not accept consultation codes anymore, you’ll need to use another appropriate E/M office visit code from the 99201-99214 (Office or other outpatient visit …) range for a pre-operative clearance encounter, based on the provider’s documentation. Use an office or other outpatient E/M code (99201–99215) when the service is provided in an outpatient setting and an initial or subsequent hospital care code (99221–99223 or 99231–99233) for encounters in the inpatient setting.

“Keep in mind, whatever code you use, the intent of the visit along with the requirements for a consultation must be met,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal at ACE Med in Pittsburgh, Pa. “Even though Medicare doesn’t cover the consultation codes, they still look for that letter back to the requesting providers.”

Watch out: A well-visit or other preventive service code is not appropriate for a pre-op clearance exam.

Check the notes: Keep in mind that if you are billing a consultation code, your provider’s documentation must include a request for the pre-op exam, notes on the rendering of the services, and a return letter or report to the requesting provider.

Choose the Right Diagnosis Code

In the past, pre-op clearance encounters were tied to V codes for the diagnosis. Now, you’ll choose a Z code under ICD-10, Cobuzzi says.

In the past you selected from codes in the V72.8_ series, such as:

• V72.81 — Preoperative cardiovascular examination
• V72.82 — Preoperative respiratory examination
• V72.83 — Other specified preoperative examination
• Now, you’ll decide between codes in the Z01.81_ series, such as:
• Z01.810 — Encounter for preprocedural cardiovascular exam
• Z01.811 — Encounter for preprocedural respiratory examination
• Z01.818 — Encounter for other preprocedural examination

You would include a primary diagnosis explaining the special circumstances of the encounter, along with the diagnosis of the condition requiring surgery. The first diagnosis will be “any signs, symptoms or abnormal diagnostic studies that support medical necessity for the consultation,” Cobuzzi says. “Then second, you list reason for the surgery.” You’ll also list any pertinent findings from the encounter.

Example: An orthopedic surgeon asks your pulmonologist to confirm that a patient with chronic obstructive pulmonary disease (COPD) is able to undergo surgery for a knee replacement. The pulmonologist might, for example, include both COPD (for instance, J44.1, Chronic obstructive pulmonary disease with [acute[ exacerbation) and knee arthritis (such as M17.10, Unilateral primary osteoarthritis, unspecified knee) as secondary diagnoses since he is clearing a patient for the surgery.

Differentiate Pre-Op Clearance and H&P

Pre-op clearance encounters are different than pre-op history and physicals (H&Ps). If the physician performing the surgery is seeing the patient just to perform a general physical to confirm the surgery is still the best course of action, but the decision for surgery was previously made, that encounter is included in the global surgical package of the procedure. That means you cannot separately report that E/M encounter