Orthopedic Coding Alert

Question: We recently sent a patient to her primary- care physician (PCP) for a preoperative clearance due to her chronic medical problem of COPD. The PCP's office called to ask us which diagnosis and procedure codes we would be using for the surgery, as well as the amount we-d be charging for the surgery. We do not share our fee schedule with other physicians, so I was not willing to tell them the charge. The PCP personally called our surgeon and complained because he said it is his standard to charge 10 percent of the surgery fee for his pre-op clearance. He uses modifier 56 on the surgery code for this service. Is this accurate? We sometimes perform surgical clearances for other physicians if our patients have recently undergone hip replacements or other major procedures, and we always bill a consult for those because our opinion is being requested.

Idaho Subscriber

Answer: Most insurers will not accept modifier 56 (Preoperative management only) under these circumstances. Coding experts say that the PCP's examination was to confirm that the patient's chronic conditions were in check, not to perform the preoperative workup that the surgeon does immediately prior to operating. Most insurers advise that the PCP should report an office visit or a consult code in this situation, whichever is applicable.

For example, the policy for Regence BlueShield of Idaho states, -Modifier 56 identifies the preoperative management for the procedure. This modifier is rarely used as the preoperative management is usually reported by evaluation and management codes.-

If your insurer publishes similar guidelines, the PCP in this case should bill a consult code if he meets the consult requirements, with V72.83 (Other specified preoperative examination) as primary followed by the diagnosis for the surgery and then 493.xx for the COPD.

According to the May 1997 CPT Assistant, -Many third-party payers include in their definition of global physician services the preoperative management, surgical procedure, and postoperative management- In some specialties, the internal medicine physician (e.g., a cardiologist) provides the preoperative and postoperative management related to the medical component of the pa-tient's care. In this case, you should check with the third-party payer(s) for the preferred method of reporting.-