Primary Care Coding Alert

Question: What is the correct method to bill a pre-surgical physical 99244 (office consultation) so that insurance companies will pay the office visit as well as the labs performed? We are having difficulty getting a couple of insurance companies to pay when we bill with diagnosis code V72.84 (pre-operative examination, unspecified). My experience has been that they may or may not pay the office visit. If they do pay, however, they will pay only the office visit and not the labs.

Cindy Johanneck
MedComm, Westerville, Ohio

Answer: This is an ongoing challenge for coders and practices that provide this sort of physical. You, of course, are required to code only for the service rendered. And unfortunately, that may mean that many carriers will disallow general pre-op lab services.

If the pre-op service you are providing is clearance for surgery for another physician, you should list the second diagnosis (V72.84 is the first) as the medical reason requiring the clearance (i.e., a heart condition like congenital mitral stenosis746.5). Nonetheless, the carrier may not pay for all the labs for all the patients unless there is an underlying reason for performing the lab, not simply that We order these for all patients having surgery.

In any event, always get a waiver signed by the patient (even those who do not rely on Medicare) to let them know up front that the cost of these services may be their responsibility. Be prepared to appeal those cases where the patient does have a specific underlying condition that requires special testing (i.e., ICD-9 493.90, asthma, unspecified, without mention of status athsmaticus).

Coders should note that CPT states that the actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of evaluation and management services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code.