Podiatry Coding & Billing Alert

Question: I'd like to know what is entailed in a pre op visit. We have a provider who does surgery on Friday. Each Tuesday prior to surgery, he sees the patient to go over any labs or x-rays that he had previously ordered for their surgery. He feels that a lot of time goes into this visit, and due to the lab results the patient does not always end up having surgery. Can I bill this service or is it considered pre-op?

Answer: A pre-op visit/exam is a physician's assessment of a patient's risk for complications before and after surgery. It includes EKG with interpretation, lab work, and plan of care assessment preand post-op. A lot of time does go into those visits and they are payable by Medicare and most third-party payers when there is medical necessity with adequate documentation.

Most podiatrists will bill that time using an E/M code. The diagnoses on the claim have to indicate that it was for a pre-op exam, the reason for the surgery, and the patient's underlying medical problems. The payer will determine medical necessity.