Primary Care Coding Alert

Question: An FP performs a pre-op clearance that an out-of-state surgeon requests on a private payer's patient. Does CPT's pre-op visit-surgery inclusion apply to our FP, or could I code a level-four office visit for a solid exam with labs ordered?

Answer: CPT's surgical package includes, "subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)," according to the surgery guidelines. The inclusion applies to the physician or a same-specialty physician within the same group who is reporting the surgery code. Since your FP is not performing the surgery, the visit is not subjected to the package.

Pre-op clearance encounters often qualify as consultations. If the encounter meets a consultation's requirements -- 1) a request from another appropriate source, 2) rendering of services, and 3) a written report (for outpatient consults) to the requesting source -- use a consult code (99241-99245, Office consultation for a new or established patient -).

Because the out-of-state surgeon has requested the E/M service, the visit in your example meets a consult's first criteria. The requesting physician does not need to specify pre-op "consult." By sending the patient to your office with an H&P form to complete, the surgeon is asking for your physician's opinion on whether the patient is fit for surgery and can withstand the procedure and the anesthesia. Your physician can stress the encounter's intent by noting in his report, "Thank you for your request on whether Patient XXX can undergo XXX. He is XXXXX and so I recommend -"

When compared to the same-level office visit, consultation codes contain the same medical decision making type but increased history and examination. In addition, outpatient consultation codes require three of three key elements, as opposed to two of three for an office visit.

If the documentation you have supports a detailed history, detailed examination, and medical decision making of moderate complexity (99214 for an office visit), you would be at a 99243 (detailed history, detailed exam, medical decision making of low complexity) for an office consultation.

Information for You Be the Coder and Reader Questions provided by John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop and Associates; Joan Gilhooly, MBA, CPC, CHCC, president and consultant with Medical Business Resources LLC in Deer Park, Ill.; and Annette Grady, CPC-Ortho, CPC-H, CPC-I, CPC-P, CCS-P, PCS, FCS, auditor with The Coding Network.