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Primary Care Coding Alert

READER QUESTIONS:

Use 99241-99245 When Pre-Op Meets 3 Criteria

Published on Tue Sep 11, 2007

Question: What is the CPT code for a pre-op exam?


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Answer: No CPT code exists specifically for a preoperative examination. FPs typically perform preoperative exams for surgical clearance requested by a surgeon--a scenario that typically falls under a consultation (99241-99245, Office consultation for a new or established patient -).

But if the encounter does not qualify as a consultation, you should instead report an office visit (99201-99215, Office or other outpatient visit -).

Use a consultation code when:

- another professional requests the consult

- the FP renders her opinion and

- she sends a report to the requesting source. Documentation in the chart should clearly support these consultation requirements. For instance, if a dentist requests your FP's opinion on a patient's ability to withstand anesthesia, assign 99241-99245 with ICD-9 codes that indicate any underlying condition, the type of preoperative exam (V72.81-V72.84), and the reason for the surgery.
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