Pulmonology Coding Alert

Visit setting and type of payer will determine coding for an E/M service before surgery.

Usually, you can’t report a preoperative visit with a patient the day before a major surgical procedure (i.e., procedure identified with a 90-day global period) as the visit is included in the surgical global fee. However, if the surgeon sends the patient to your pulmonologist for surgical clearance, then your coding options can change.

Make sure you know how to decipher billable and non-billable pre-operative encounters with these tips.

Tip 1: Determine the Setting

When the provider performing the pre-op clearance sees the patient, you can report an evaluation and management code. Which code you’ll use depends on whether the encounter takes place in the office or hospital and which payer you are billing.

For your Medicare patients requiring pre-op clearance, you must report an office or other outpatient evaluation and management (E/M) code (99212–99215, assuming the patient is established) when the service is provided in an outpatient setting.

If the physician performs the service in the hospital inpatient setting, you should submit an initial or subsequent hospital care code (99221–99223 or 99231–99233). Medicare no longer recognizes the CPT^® codes for outpatient (99241-99245) or inpatient (99251-99255) consultations.

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.

Example: Suppose a Medicare patient with COPD visits your pulmonologist to gain clearance for knee replacement surgery. The orthopedic surgeon wants confirmation that the patient’s lungs are strong enough to handle the procedure and the post-procedure recovery.

Solution: The pulmonologist will typically choose the most appropriate E/M office visit code from 99201-99214, depending on the specifics of the encounter and the payer. Link Z01.811 (Encounter for preprocedural respiratory examination) as the primary diagnosis along with the diagnosis of the condition requiring surgery.

The pulmonologist might report 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) for the visit, and include both COPD (for instance, J44.1, Chronic obstructive pulmonary disease with [acute] exacerbation) and knee arthritis (such as M17.10, Unilateral primary osteoarthritis, unspecified knee) as secondary diagnoses to Z01.811. He should also include diagnoses for any other co-morbid conditions.

Tip: Ask your physicians to include a statement at the beginning of dictation about the surgical clearance. They might state, “Patient is here for perioperative risk stratification for knee replacement surgery due to _________ (chronic conditions).”

Tip 2: Choose the Correct ICD-10 Codes

You have a choice from the following Z codes:

• Z01.810 — Encounter for preprocedural cardiovascular examination
• Z01.811 — Encounter for preprocedural respiratory examination
• Z01.818 — Encounter for other preprocedural examination.