EM Coding Alert

Know when you can — and can’t — report an E/M service before surgery.

If a surgeon performs a preoperative visit with a patient the day before he does surgery on her, that visit is included in the surgical global fee. But if the surgeon sends the patient to a different physician for surgical clearance, that physician’s coding options change.

Make sure you know how to decipher billable and non-billable pre-operative encounters with these tips.

Determine the Setting

When the provider performing the pre-op clearance sees the patient, you can report an evaluation and management code. Which code you’ll use depends on whether the encounter takes place in the office or hospital and which payer you are billing.

For your Medicare patients requiring pre-op clearance, you must report an office or other outpatient evaluation and management (E/M) code (99212–99215, assuming the patient is established) when the service is provided in an outpatient setting.

If the service is performed in the hospital inpatient setting, submit an initial or subsequent hospital care code (99221–99223 or 99231–99233). Medicare no longer recognizes the CPT^® codes for outpatient (99241-99245) or inpatient (99251-99255) consultations.

Non-Medicare: If the patient’s payer still accepts consultation codes, follow CPT^® instructions for reporting consultation services with 99241-99245 for a new or established patient in your office, or 99251-99255 for a new or established patient in an inpatient setting. If the non-Medicare payer follows Medicare’s lead and no longer recognizes the consultation codes for payment, then you will need to report an appropriate office visit or hospital visit code for the encounter, just as you would for Medicare.

Example: Suppose a Medicare patient with COPD visits your pulmonologist to gain clearance for knee replacement surgery. The orthopedic surgeon wants confirmation that the patient’s lungs are strong enough to handle the procedure and the post-procedure recovery.

Solution: The pulmonologist will typically choose the most appropriate E/M office visit code from 99201-99214, depending on the specifics of the encounter and the payer. Link V72.83 (Other specified preoperative examination) as the primary diagnosis along with the diagnosis of the condition requiring surgery.

The pulmonologist in our example might report 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) for the visit, and include both COPD (for instance, 491.21, Obstructive chronic bronchitis with [acute] exacerbation) and knee arthritis (such as 715.16, Osteoarthrosis localized primary involving lower leg) as secondary diagnoses to V72.83. He should also include diagnoses for any other co-morbid conditions.

Tip: Ask your physicians to include a statement at the beginning of dictation about the surgical clearance. They might state, “Patient is here to get clearance for knee replacement surgery due to _________ (chronic conditions).”

Watch for ICD-10 Changes

You have typically been limited to E/M codes linked to V codes for diagnoses. However, that option will change drastically under ICD-10 next year, forcing you to move to Z codes for these visits.

Right now your surgical clearance codes are limited to the following:

• V72.81 — Preoperative cardiovascular examination
• V72.82 — Preoperative respiratory examination
• V72.83 — Other specified preoperative examination
• V72.84 — Preoperative examination unspecified.

Under ICD-10, however, you’ll report from the following list:

• Z01.810 — Encounter for preprocedural cardiovascular examination
• Z01.811 — Encounter for preprocedural respiratory examination
• Z01.818 — Encounter for other preprocedural examination
• Z01.812 — Encounter for preprocedural laboratory examination.

Remember to change over your superbills and the codes within your system prior to Oct. 1, 2014 to ensure that you’re reporting ‘Z’ codes at that point rather than ‘V’ codes.