Gastroenterology Coding Alert

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Question: How can I receive reimbursement from Medicare for a preoperative clearance visit when the patient is at high risk (e.g., for cardiac or respiratory diagnoses)? I have heard that I can bill a consultation or initial visit to Medicare if I bill first with the preoperative cardiac code (V72.81) and second with V76.51 (Special screening for malignant neoplasms; colon). Tennessee Subscriber

Answer: You may find it difficult to receive proper reimbursement for a preoperative clearance consultation because carriers have different interpretations of how to code for the service. Denials are common even when you use the appropriate V codes. You should use the appropriate preoperative V code rather than the condition that warrants the surgery to justify the examination. However, medical necessity for such preoperative clearance remains at the discretion of the local Medicare carrier.

You must use one of the four appropriate preoperative examination ICD-9 codes when billing for a preoperative consultation:
V72.81 Pre-op cardiovascular exam
V72.82 Pre-op respiratory exam
V72.83 Other specified pre-op exam
V72.84 Pre-op exam, unspecified. Medicare carriers will pay for or deny a preoperative clearance based on the medical diagnosis and the careful choice of a secondary diagnosis to indicate the reason for the surgery. Unless the physician sees a patient for a specific problem, the first diagnosis should be the preoperative V code. The second diagnosis is the reason for the surgery. The third and fourth diagnoses indicate any complications that may be present.

Depending on the situation, you should report a new patient code (99201-99205) or established patient code (99212-99215) when the physician performs the examination in an office or outpatient setting.