Primary Care Coding Alert

Hint: Your FP's recs are the ones to count under mgt options.

When a patient needs preoperative clearance for a major surgery, don't scratch your head over the applicable table of risk selections -- focus on your doc's role. Test your major versus emergency surgery savvy and who gets the credit for surgical recommendations with this real world case.

A 45-year-old patient fell from a ladder, hit a fence on the way down, and fractured his elbow. Ortho is taking patient to surgery for an open reduction of the fracture and has asked my physician to evaluate the patient for pre-operative clearance. My physician clears the patient, who has no identified risk factors for surgery. Ortho takes the patient into the OR in the following 24 hours. Regarding my physician's E/M, I have two auditing questions:

1. Do Details Count as HPI?

Should you count the accident's details ("on a ladder," "hit a fence") as context in history of present illness (HPI)?

Answer: You can count either the phrase "on a ladder" or "hit a fence" as context for history of present illness (HPI). Context is what the patient was doing when the injury/condition/illness occurred. The physician receives credit for context only once, regardless of the number of details documented.

2. Is This Emergency Surgery?

"Under the Table of Risk, should I consider this emergency major surgery?" the auditor asks. "While my physician is not the one performing the procedure, she is determining the patient's suitability for surgery. Is there any published guideline to differentiate between 'elective' and 'emergency' major surgery, as well as who can count it?" wonders the FP coder. For Management Options Selected, attribute any surgery to the recommender. "Since the surgeon was the one that recommended surgery, the Management Options Selected in the Table of Risk is attributed to the surgeon," says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding education and billing compliance for UPMC-Physician Services Division in Pittsburgh.

When selecting the FP encounter's level of risk, do not count the surgical management option, as the FP isn't doing or hadn't been the one to recommend the surgery. "To determine the level of risk associated with the FP's preoperative clearance encounter with the patient, the FP could count Presenting Problem(s) that are examined within the Table of Risk," Berman points out.

Apply Your Knowledge

Let's apply the emergency and risk factor definitions to the pre-op clearance scenario. "Open fracture reduction 24 hours after surgical clearance would not be emergency surgery," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education with University of Washington Physicians. "Emergency surgery is surgery that must be performed immediately."

Solution: Both the surgeon and the FP would have a moderate level of risk for their respective encounters with the patient. Here's why:

The surgeon would have a moderate level of risk for selecting the elective surgery without identified risk factors. "Very typically, clearance for surgery would result in the decision that the patient could have elective major surgery without identified risk factors," Bucknam adds. The FP would have to rely on the presenting problem(s) evaluated. In this case, the presenting problem is an acute complicated injury, which is a moderate level of risk.