General Surgery Coding Alert

Question: Can we charge for a preoperative visit when a history and physical (H&P) for surgical clearance is performed before surgery? If so, what code do we use?

Maine Subscriber

Answer: If the clearance you are speaking of is actually the preparation of the H&P that is required by the hospital prior to surgery, the service is included in the global fee for the procedure and is not billable separately. But the H&P may be separately billed when it occurs more than 24 hours ahead of the surgery and satisfies Medicares medical-necessity requirements. In such cases, it would be billed as an established patient visit, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill., who notes that if the H&P (or admission) was done the same day as an unscheduled or emergency procedure and the need for the surgery wasnt decided until after that visit, then the H&P can be billed with a modifier -57 (decision for surgery). A recheck on the patient can be billed using established patient visits 99211-99215 as long as it is done more than 24 hours before the surgery date.

Typically surgeons can bill for two things: the E/M service (i.e., workup and appropriate H&P) that led to the decision for surgery, and the surgery itself. Preoperative H&P done separately is more of a paperwork issue, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator based in North Augusta, S.C. The information obtained for this document is important to the patients care, but ultimately it is created because of requirements for the hospital, so the reimbursement for this service is included as a portion of the surgical reimbursement.

For example, if the physician makes a decision to perform surgery on Dec. 1, schedules the procedure for Dec. 10 and brings the patient back on Dec. 7 for an H&P, the H&P is not billable even though it does not fall within the global period of the procedure (which begins the day before the procedure if it has a 90-day global) because carriers likely will not consider the presurgical H&P medically necessary, she says. The correct diagnosis for this service, when performed on a separate visit from the decision for surgery, is V72.83 (other specified preoperative examination).

If the service is performed the day before or the day of major surgery, it definitely falls within the procedures global period. The global package includes many services, including preoperative visits after the decision for surgery, beginning with the day before the major surgery and the day of surgery for minor surgeries.