Primary Care Coding Alert

Question: What CPT^® code should we submit for pre-op clearance by one of our family physicians? Is the service payable by insurance?

Wisconsin Subscriber

Answer: Yes, this is a billable service. How you report may depend on the payer. For Medicare patients requiring pre-op clearance, report the appropriate E/M code based on your physician’s documentation of the visit. Most patients in this situation probably will be established with your practice, which means you’ll choose from 99212-99215, if the patient is seen in the office. If the patient is new, select from 99201–99205.

If the service is performed in the inpatient setting, you’ll report an initial or subsequent hospital care code instead (99221–99223 or 99231–99233).

Non-Medicare: If the patient’s payer still accepts consultation codes, follow CPT^® instructions for reporting consultation services with 99241-99245 for a new or established patient in your office, or 99251-99255 for a new or established patient in an inpatient setting. If the non-Medicare payer follows Medicare’s lead and no longer recognizes the consultation codes for payment, then you will need to report an appropriate office visit or hospital visit code for the encounter, just as you would for Medicare.