Primary Care Coding Alert

File claims for non-consult services, but make sure patient knows some preop E/Ms arent covered.

Your FP provides a preoperative E/M service. This is automatically a consultation & right?

Wrong. Not all pre-op E/Ms qualify as consults.

Separate myth from fact with this pre-op consult FAQ:

1: Who Needs Pre-Op Consults?

Typically, patients who get pre-op consults have a chronic or comorbid medical condition, confirms Tina Landskroener, CPC, CCS-P, PCS, business office manager for Blessing Physician Services in Quincy, Ill.

If the surgeon believes the patient has an underlying condition that could complicate the outcome of the surgery, a preoperative consultation by the primary care physician may be necessary, she says.

When a patient is taking medication or undergoing long-term treatment for a condition, it increases the odds that he will require a consultation before a major surgical procedure. Some examples of chronic conditions that might necessitate pre-op consult include:

" chronic obstructive pulmonary disorder (COPD) (496)

" diabetes (250.xx)

" coronary artery disease (414.xx)

" essential hypertension (401.x).

Example: An established patient with a history of coronary artery disease (CAD) is scheduled to have a total knee replacement. The orthopedist asks the FPs opinion on the patients CAD to make sure he can stand the rigors of the procedure; the orthopedist also wants the FP to weigh in on how to best manage the patients CAD during the surgery. The FP performs a level-two consult in the office, and sends a report back to the orthopedist with recommendations.

This is a consultation; on the claim, report an office or outpatient consultation code such as 99242 (Office consultation for a new or established patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making &) for the service.

(Note: For more information on choosing diagnosis codes for your pre-op consults, see Steer Clear of Denials by Coding for Consults on Case-By-Case Basison page 60.)

2: What Makes Pre-Op Service a Consult?

To report a pre-op consult, you must document a Request for an opinion, the Reason for the request, and a Report in response to the requesting physician.

The note back to the requesting physician needs to be clear and concise, [specifying] what the recommended treatment plan should be, explains Sharlene Scott, CPC, CPC-H, CCS-P, CCP-P, CPC-I, CPMA, PMCCapproved instructor at Coding Academy of America Inc. in Baltimore.

In the note back to the requesting physician, the FP might consider including recommendations on how the physician should manage the patients condition during surgery.

In your consult documentation, consider including the name and specialty of the requesting physician, recommends Landskroener.

Follow this guidance: According to WPS Medicare, a payer for several Midwestern states, If the services provided are clearance for surgery, then the physician must document the findings of the E/M in the patients medical record & the surgeon must request opinion or advice of the physician regarding evaluation and/or management of a specific problem.

3: How Should I Code Non-Consult Pre-Ops?

If a patient comes in for a preoperative E/M that does not qualify for a consultation, code it as an E/M service based on the physician notes and setting.

A patient without a chronic illness might request and receive a preoperative E/M if he is nervous about surgery; it might also be for routine or screening purposes, reports Cynthia Swanson RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP in Omaha, Neb.

If the patient receives a pre-op E/M for any of these reasons, insurance might not cover it, so be sure he knows that before receiving the E/M.

Example: An established 27-year-old patient without any chronic or comorbid conditions is scheduled to have surgery on his fractured ribs. Although the surgeon sees no underlying condition in the patient that might affect the procedure, the patient still reports to the FP before surgery to ease his mind. The FP performs a level-two E/M and sends the patient home.

This is an office visit, not a consult. Report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making &) for the service.