Primary Care Coding Alert

Question: Ophthalmologists always request our opinion on whether patients scheduled for cataract surgery can undergo surgery. How do we get Medicare to cover these preoperative consultations?

Michigan Subscriber

Answer: Technically, the surgery's global package includes the preoperative exam performed by the operating physician. Medicare, however, will cover preoperative consultation (99241-99245, Office consultation for a new or established patient, which requires these three key components-) for patients for whom the Medicare carrier or Medicare administrative contractor (MAC) considers it medically necessary (such as patients who have a comorbidity that may complicate the surgery). Check with your Medicare carrier or MAC to see if it has a local coverage determination on this matter.

Preoperative consultations are generally payable for new or established patients performed by any physician or qualified nonphysician practitioner at the request of a surgeon, provided all the consultation code requirements are met and the service is medically necessary and not routine screening.

According to ICD-9 guidelines, you should first report a code from V72.81-V72.84 (Other specified examinations), to describe the pre-op consultation. If available, list the ICD-9 codes for the condition that prompted surgery (for instance 366.xx, Cataract) and for the comorbidities that prompted the preoperative medical evaluation, such as hypertension (for instance 401.x,Essential hypertension) or diabetes (250.xx), or other diagnosis and conditions affecting the patient.