Internal Medicine Coding Alert

One of the most common consultations performed by internists are the preoperative examinations to clear patients for surgery. Getting paid for these consults can be difficult due to confusion over which ICD-9 codes should be used to indicate the reason for the consultation.

A patient may be undergoing hip surgery, but the surgeon is concerned that the patients diabetic condition may complicate surgery, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., in Spring Lake, N.J. The surgeon will ask an internist to perform an examinationa history, physical and perhaps some diagnostic teststo ensure the patient is able to undergo the procedure. The internist is giving his opinion on whether the patient is healthy enough to undergo surgery.

ICD-9-CM contains a series of codes specifically for reporting preoperative examinations, the V72.8 series (e.g., V72.82pre-operative respiratory examination, V72.83other specified pre-operative examination), says Brink. These are the correct codes to use as the primary diagnosis linked to the CPT consult code for the visit, she advises.

Many payers, including Medicare, do not pay for screening examinations. Some physicians have reported these consults linked to ICD-9 codes based on the complicating condition or to the reason for the surgery itself, which is not correct, says Brink.

The reason the patient is being seen for the consult is a preoperative examination, and that should be the primary diagnosis code reported, Brink says.

The complicating condition or reason for the surgery can be reported as a secondary diagnosis code after the V72.8x code, she says. This may cause problems with reimbursement, she acknowledges. But that is where the difference between correct coding and coding for reimbursement comes in.

Some physicians and consultants have recommended coding an ICD-9 for the reason for the surgery as a primary diagnosis, with the V code as a secondary diagnosisreasoning that the exam is necessitated by the upcoming surgical procedure, which therefore is the reason for the visit. The V code would notify the payer that the service is a preoperative examination. (See Update on Billing for Preoperative Clearance Examinations, on page 19 in the March 1999 Internal Medicine Coding Alert.) But Brink recommends using the V code as a primary ICD-9 code and appealing any denials due to automatic rejections from payers.

Brett Baker, third-party relations specialist at the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), says, We have been getting a lot of complaints that there are carrier-specific differences in how these services are being reimbursed.

ACP-ASIM is about to enter negotiations with officials at the Health Care Financing Administration (HCFA) to resolve these differences at the national level. We are gathering information from various committees and are putting together a proposal to take to HCFA, so that we can get a clarification on when and how these visits should be reported, Baker says.

So far, HCFA has acknowledged that preoperative examinations are not screening and should not be rejected as such. And in discussions with provider relations personnel at HCFA, they have advised that the V72.8x codes should be used as diagnosis codes for these examinations. They did not specifically stipulate that the V code must be first, but they did say it was the appropriate code to use, and that is an issue that we will be addressing, he notes.

ACP-ASIM will also seek clarification on what, exactly, constitutes a preoperative clearance exam vs. a pre-surgery history and physical. When a physician performs surgery, a history and physical is part of the evaluation and management service included in the overall surgical procedure, adds Baker. In some situations, you may have a surgeon ask an internist to perform this history and physical. This does not constitute a clearance examination or consult but is really a part of the surgical service.