Neurology & Pain Management Coding Alert

The Centers for Medicare and Medicaid (CMS, formerly HCFA) has instructed all local Medicare carriers to accept V codes for preoperative clearance. Until now, many carriers have routinely denied reimbursement for preoperative consults by neurologists and other specialists. The announcement singles out four preoperative clearance ICD-9 codes. These are:
 

V72.81 (preoperative cardiovascular examination);

V72.82 (preoperative respiratory examination);

V72.83 (other specified preoperative examination);   

V72.84 (preoperative examination, unspecified)

 
The clarification, which revises section 15047 of the Medicare Carriers Manual (MCM), states that V72.81-V72.84 should be used to indicate medical necessity for preoperative clearance evaluations.
 
Medicare transmittal R1707-B3, issued May 31, 2001, instructs carriers to "delete any processing edits that deny claims or identify for manual review V72.81-V72.84." However, "claims containing these codes are subject to medical necessity determinations as described in MCM section 15047H."
 
According to the new language in section 15047C, Medicare will pay for all medically necessary preoperative clearances, such as those that involve "evaluating a patient's risk of perioperative complications and to optimize perioperative care." Local Medicare carriers retain the discretion to determine the medical necessity, CMS says.
 
"Medicare probably issued this to set the carriers straight," says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. "Many carriers routinely denied these services on first submission when the V codes were correctly used as a primary diagnosis."
 
After the denial was appealed and the claim was reviewed manually, it usually was paid, Callaway says. But, she notes, not all denials are appealed. The new revision should result in far fewer denials when neurologists use a V code as the primary diagnosis.
 
According to the revised language in section 15047G, "all claims for preoperative medical examination and preoperative diagnostic tests (i.e., medical evaluations) must be accompanied by the appropriate code for preoperative examination (e.g., V72.81- V72.84)."  
 
Additionally, the appropriate code for the condition(s) that prompted surgery must also be documented. Other diagnoses and conditions affecting the patient (presumably, the condition that concerned the surgeon enough to send the patient to the neurologist for a preoperative clearance) should also be documented, if appropriate.
 
In other words, when a patient is sent to a neurologist for preoperative clearance, the appropriate V code, rather than the condition that prompted the concern or the condition that warrants surgery, should be listed first to justify the examination. In fact, the transmittal specifies, "The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81-V72.84)."

Payment for Preoperative Consults 
 
The clarification also means that neurology coders can use the appropriate ICD-9 code to get paid for preoperative consults, Callaway says, noting that in states where local Medicare carriers routinely deny consult claims with preoperative clearance V codes as the primary diagnosis, some neurologists would use the condition (parkinsonism or seizure disorders, for example) as the primary diagnosis so that the claim would be paid. This is incorrect coding because the patient did not see the neurologist as a result of problems related to the condition, but rather as a preoperative clearance.
 
The call to include the diagnosis code that prompts the surgery also may reduce the number of denied claims (and manual reviews), says Arlene Morrow, CPC, a coding and reimbursement specialist in Tampa, Fla.
 
"When, for example, the orthopedist sends a patient to the neurologist to evaluate the patient's seizure disorder, the UPIN number for the orthopedist needs to match an orthopedic diagnosis (i.e., the diagnosis that prompted the decision to perform a hip replacement)," Morrow says.
 
The diagnosis that prompted the surgeon to request the preoperative clearance should also be included, because it provides additional medical necessity and indicates and explains why, for example, V72.83 was used (to indicate a particular specialty, such as neurology) as opposed to V72.84 (used mainly to report preoperative clearances by primary care physicians).
 
Medicare carriers can only read one diagnosis per line item (service or procedure) on an electronic claim, and even when the claim is adjudicated manually, the reviewer cannot see the additional diagnoses, until and unless a paper claim is provided.
 
However, the neurologist is also likely to perform diagnostic tests to evaluate the level of risk to the patient, such as carotid duplex scanning or a brain CT scan. When such tests are performed, one additional diagnosis can
be submitted electronically for additional services or procedures reported.

 
The key factors that determine whether a pre-operative consult should be billed, Morrow says, are much the same as for any other consult: Follow all the consultation criteria and document that the consult was medically necessary.
 
Medicare's criteria for distinguishing a consult from another E/M service, which can be found in Section 15506 of the MCM, are as follows:
 
1. It is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation). 
 
2. A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record.
 
3. After the consultation is provided, the consultant prepares a written report of his/her findings, which is provided to the referring physician.

 
Although there has been much controversy about what constitutes a transfer of care, this issue has less of an effect on preoperative clearances, because care typically is handed back to the surgeon.
 
"It's not so much a question of clearing the patient for surgery as assessing the risk to the patient and offering advice on how to best manage him or her during surgery," says Marian LaMonte, MD, MSN, an associate professor of neurology and director of acute stroke services with the department of neurology at the University of Maryland in Baltimore. "Rather, the preoperative consult should be thought of as a risk assessment." What the surgeon wants to know, she says, is the extent of the patient's condition, and what needs to be done to make sure he or she survives and benefits from the procedure.
 
For example, a patient who had a CVA (cerebral vascular accident) requires a bowel resection. Because of the patient's prior condition, the general surgeon wants the neurologist's advice on how to best protect the patient's brain during surgery, LaMonte says.
   
If, for example, the post-CVA patient is anemic, the surgeon may be concerned about maintaining a sufficient blood flow to the brain during the colectomy, which could involve the loss of significant amounts of blood, she says.
 
Similarly, if the patient is hypertensive, the surgeon may request a preoperative consultation by a neurologist to obtain advice on how to best manage the patient's blood pressure during and after surgery.
 
If the preoperative consultation leads to the determination that surgery should not be performed (because the patient, typically elderly, is too frail, has dementia or has a poor outlook because of other conditions and is unlikely to benefit from the procedure) a consultation may still be billed. The surgeon's request for an opinion or advice must be in writing, and the neurologist must provide the surgeon with a written report (in the hospital, an entry in the patient's medical record is sufficient).
 
"The requesting surgeon needs to set it up appropriately," Morrow says. "The written request should include words to the effect that 'I am asking for your opinion on whether patient X is a suitable candidate for surgery.' And the neurologist needs to flesh that out in his or her own documentation, as follows: 'I am seeing patient X at the request of general surgeon Y, to evaluate the patient's parkinsonism and fitness for surgery.' If all this is done and the report is sent back to the surgeon, it qualifies as a consultation." 
 
Morrow also recommends that when writing their reports, neurologists use the term "requesting surgeon" rather than "referring surgeon" because in the past, some carriers have denied consultation claims because they incorrectly assumed that a referral implied a transfer of care, even though MCM Section 15506 uses the term numerous times.
 
Finally, some neurologists may believe they should not bill for a preoperative consult when performed on their own patient. This is incorrect, notes Mary Bland, CPC, a coding and reimbursement specialist in Mesa, Ariz.
 
"Just because they're being treated by a neurologist anyway doesn't mean they don't need preoperative clearance by the neurologist," Bland says, noting that a preoperative consultation (or any other consult) may be billed for both new and established patients as long as
an pinion is rendered and the other consultation criteria have been met.
 
However, a consult should not be billed if:

  Any of the criteria are not met or documented (a visit [office or inpatient] should be billed instead;

  The neurologist is performing the history and physical because the surgeon does not want to perform the preoperative evaluation included in the surgery's global package.

 
Note: If the neurologist provides a preoperative consultation and then sees the patient postoperatively, those visits should be billed with the appropriate level established patient or subsequent inpatient care codes, according to Section 15506F of the MCM.