Podiatry Coding & Billing Alert

E/M Coding:

Answer the How, What, When and Why for Preoperative Evaluations

Published on Wed May 15, 2024

Don’t forget to check for comorbid conditions.

Knowing how to navigate and select all of the codes necessary to report a preoperative encounter takes a lot of knowledge. Boost your evaluation and management (E/M) service coding confidence and remember that some ICD-10 knowledge is crucial, too.

Read more about the ins and outs of reporting a pre-op evaluation.

Focus on the Decision for Surgery

One common source of confusion has to do with separate E/M billing. For example, let’s say the podiatrist sees a patient and schedules an operation based on that visit. When the patient comes back the day before the surgery for a pre-op evaluation, can you bill another E/M even if nothing has changed from that first encounter?

The answer may depend on the payer. For payers such as Medicare that have global surgery guidelines, you must bundle certain services before and after the surgery based on the rules for the appropriate global period.

So, under Medicare rules, once the provider makes the decision for surgery, you should not separately bill any preoperative visits related only to the surgery. In other words, the prescreening visits don’t usually present new information that warrant the need for an E/M service.

Exception: If the patient’s situation changes between the first and second visits before surgery, you might be able to make the case for billing another office/outpatient E/M.

For instance, if the patient develops a serious medical condition that is unrelated to the reason for the surgery, but could impact the outcome, the surgeon may perform additional services that increase the level of medical decision making (MDM) and, if properly documented, could allow you to bill a separate E/M visit.

Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, director of healthcare training and practice support at Healthcare Inspired LLC, in Bella Vista, Arkansas, gives the following example:

A patient initially visits a podiatrist for treatment of Morton’s neuroma. During the first visit, the podiatrist recommends surgery. However, prior to surgery, the patient develops a severe diabetic foot ulcer, which is unrelated to the Morton’s neuroma but could significantly impact the outcome of any future surgical intervention for the neuroma. During the second visit, the podiatrist discusses surgical management of the Morton’s neuroma but also evaluates and manages the diabetic foot ulcer, which involves a comprehensive assessment, a wound care order, and coordination with other healthcare providers. If properly documented, the podiatrist could justify billing a separate office/outpatient E/M visit for the second encounter prior to surgery, citing the need for additional evaluation and management due to the development of the diabetic foot ulcer, which is unrelated to the initial reason for the visit.

Modifier alert: Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or 57 (Decision for surgery) when there is a separately billable E/M. Documentation must clearly support the separate service. “We need a robust paragraph of evaluation and management,” said Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal at Lehrman Consulting LLC in Fort Collins, Colorado, during his HEALTHCON 2024 presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

Learn more: You can read about global surgery guidelines at www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf.

Report Z Codes First in Some Instances

Coders also sometimes have trouble understanding when to report a code from the Z00-Z13 block (Persons encountering health services for examinations) and how to sequence that code with other diagnosis codes.

If the chief reason for the encounter is a pre-op evaluation, you should first list a code from Z01.81- (Encounter for preprocedural examinations) to describe the evaluation. Then, you should assign a code for the condition that prompted the surgery as an additional diagnosis. Remember that any conditions discovered during the screening should be reported as additional diagnosis codes.

For example, let’s say that a patient who was scheduled for a left tendon repair surgery presented for a pre-op evaluation. The physician listed the condition prompting the surgery as a tendon rupture, which codes M66.272- (Spontaneous rupture of extensor tendons, left ankle and foot); and the underlying medical condition as diabetes, which you could document with a code such as E11.9 (Type 2 diabetes mellitus without complications). In this case, you’d first list Z01.818 (Encounter for other preprocedural examination) followed by the reason for surgery (tendon rupture) then the comorbidity (diabetes).

By Lara Kline, AS, BS, Development Editor, AAPC