Primary Care Coding Alert

Question: A Medicare patient of ours is going in for surgery, and the surgeon requested that the patient see her family physician to have a history and physical done prior to the operation. What procedure code and diagnosis code should I use for this if she only came in for the history and physical?

Virginia Subscriber

Answer: Usually in this situation, the surgeon is seeking the FP's opinion on whether the patient is fit for surgery. If you document this request in the patient's medical record and provide a written report to the requesting surgeon, you should be able to report these preoperative visits using a consultation code. If the service is done in the office or other outpatient setting, use an office consultation code (99241-99245); if it is provided in the hospital, use an initial inpatient consultation code (99251-99255).

If the service does not meet the definition of a consultation, you will need to use another appropriate evaluation and management code (e.g., 99201-99215). Such non-global preoperative examinations are payable if they are medically necessary and meet the documentation and other requirements for the service billed.

In either case, you should use the appropriate ICD-9 code for preoperative examination (i.e., V72.81-V72.84). Additionally, you should use the appropriate ICD-9 code for the condition that prompted surgery. If there are other diagnoses and conditions affecting the patient (e.g., comorbid conditions such as hypertension or diabetes), you should also document those on the claim. For more information on Medicare policy regarding preoperative services, see section 15047 of the Medicare Carriers Manual online at http://cms.hhs.gov/manuals/14_car/3b15000.asp#_15047_0.

Answered by Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.