Primary Care Coding Alert

CMS's directive prohibiting local carriers from automatically denying claims containing ICD-9 preoperative evaluation codes V72.81-V72.84 is good news for family physicians and coders. These codes describe cardiovascular, respiratory and other examinations prior to surgery.

"In the past, many local carriers adopted a blanket policy and automatically denied routine pre-op tests that were conducted in the absence of a diagnosed disease related to the test," explains Susan Prophet, RHIA, CCS, CHC, director of coding policy and compliance with the American Health Information Management Association in Chicago. "They felt justified that if a patient didn't have a diagnosed heart condition, there was no reason to perform an EKG before surgery [e.g., 93000, electrocardiogram, routine ECG with at least 12 leads; with interpretation and report]. Or, if a patient didn't have a lung condition, there was no reason to perform a chest x-ray [e.g., 71030, radiologic examination, chest, complete, minimum of four views]."

The new directive eliminates this unilateral viewpoint and forces local carriers to accept the V codes supporting medical necessity when appropriate. "It does not mean that a carrier must pay for routine pre-op screenings for every perfectly healthy 65-year-old," Prophet says. However, if a patient presents with a current condition or history of a condition that might affect the success of the surgery or how well the patient might tolerate the procedure (e.g., 412, old myocardial infarction), it is likely that the pre-op screening will now be paid.

Although the precise circumstances allowing pre-op evaluations will be determined by the local carriers and communicated in local Medicare review policies (LMRPs), she notes that most coding and reimbursement professionals anticipate that many more of these tests will be paid. "This is very good news for physicians and beneficiaries alike."

She adds that the V codes should be reported as the primary diagnosis code on claim forms since they indicate the reason for the encounter. Diagnosis codes explaining the reason prompting the surgery and clinical conditions for the evaluation would be recorded in the secondary or subsequent positions.