Internal Medicine Coding Alert

Question: What's the best CPT® code for a pre-operative clearance visit?

Minnesota Subscriber

Answer: Sometimes, you'll choose the most appropriate E/M office visit code from 99201-99214, depending on the specifics of the encounter and the payer (e.g. the encounter is patient initiated or it's a Medicare patient). If the surgeon specifically requests the clearance visit and you provide a written report back to the surgeon, you can report a consult code instead (99241-99245, Office consultation for a new or established patient...), unless, it's a Medicare patient, because Medicare no longer recognizes or pays for the consultation codes. Link V72.83 (Other specified preoperative exam) as the primary diagnosis along with the diagnosis of the condition requiring surgery.

Example: A Medicare patient visits your physician to gain clearance for knee replacement surgery. The physician might report 99214 and include diagnosis 715.16 (Osteoarthrosis, localized, primary; lower leg) as a secondary diagnosis 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)." To further support the reporting of a consultation code for this service, the physician might state instead, "Patient here at the request of _____ (name of requesting surgeon) to get clearance for knee replacement surgery due to _________ (chronic conditions)."