Internal Medicine Coding Alert

Question: An orthopedic surgeon sent a patient with asthma and hypertension to our internist for a pre-operative clearance consultation prior to a total hip replacement. Our physician cleared the patient for surgery. How should we report this? I'm leaning toward reporting 99245 for the E/M service, but a co-worker says we should use 99242 or 99243.

South Carolina Subscriber

Answer: The level of care you should report for office consultations (99241-99245) depends on what your internist's documentation supports. For pre-operative consultations, you will probably use 99242 or  99243. Rarely does a physician clear a patient for surgery following a 99245 preoperative consultation. That's because the patient would have to present with a condition, such as hypertension (401.x) or asthma (493.x), that the physician would determine as too unstable to clear the patient for surgery.
 
For you to report 99245, for instance, your internist would have to determine that the patient's hypertension was out of control, which would meet the requirements for high-level decision-making. But after your physician developed a treatment plan to control the hypertension, he or she approved the patient for the hip replacement.
 
As for the 99242 or 99243, suppose your internist's documentation supports 99242. In that case, the documentation should show an expanded problemfocused history and exam, and straightforward medical decision-making that took your physician about 30 minutes to perform. You should link asthma (493.x) and hypertension (401.x), and then the reason for surgery (715.15, Osteoarthrosis and allied disorders; localized, primary; pelvic region and thigh), to 99242.
 
You'd list the reason for surgery after 493.x and 401.x, because you want to make clear which conditions could complicate or hinder the surgery. In addition, you should list V72.83 (Other specified preoperative examination), which tells your carrier that your physician performed a preoperative clearance consult.