Primary Care Coding Alert

Question: The local orthopedist requires clearance before scheduling patients for total knee replacement surgery, so we see a lot of Medicare patients for their pre-surgical exams. What is the best way to bill these visits?

West Virginia Subscriber

Answer: Because your physician is not the surgeon scheduled to perform the procedure, you can code for a pre-op exam (a pre-op exam with the surgeon is considered part of the surgical global package). Choose the appropriate office or other outpatient evaluation and management code, depending on the level of history, exam, and medical decision making involved. For an established Medicare patient, this will typically be either a 99213 or 99214. Submit V72.8x (Other specified examinations) as the primary diagnosis. You can also include the appropriate diagnoses supporting the need for surgery (the diagnosis that necessitates the knee replacement, in this example) and any other comorbid or other medical conditions that may be relevant.

For non-Medicare patients, consider using the appropriate office consultation code (99241-99245). A pre-operative clearance can meet the CPT® definition of a consultation, because the surgeon is requesting the service and the family physician's advice related to the care of a specific condition or problem. If the family physician provides a written report back to the requesting surgeon, the CPT® definition of a consultation has likely been met and may be reported as such to payers who still recognize the consultation codes.