Pulmonology Coding Alert

Question: How do I bill a presurgical physical (99243, office consultation) to get paid for an office visit as well as tests? I am having trouble getting insurers to pay when a diagnosis of V72.82 is used.

Ohio Subscriber

Answer: If the preoperative service you are providing is clearance for surgery for another physician (for example, performing a physical for one of your emphysema patients before an angioplasty that a cardiac surgeon will be performing), you should list V72.82 (preoperative respiratory examination) as the primary diagnosis. You should also use a second diagnosis, if available, which represents the medical reason requiring the clearance (i.e., 492.8, emphysema). The reason for the surgery should not be listed because the physician providing the exam is not evaluating the patient for the surgical problem. The carrier may not pay for every test for all patients unless there is an underlying reason for administering it, not simply We order these for all patients having surgery.

The E/M visit may need a symptomatic diagnosis describing the reason the patient must be cleared for surgery (i.e., asthma, chronic bronchitis, etc.). If the payer requires this for the preoperative exam to be reimbursed, the edits in place for the carrier may have to be changed to support the V72.81 (preoperative cardiovascular examination) or the V72.82. Make sure the payer is contacted if denials are common for this reason, and that they are aware that they are denying a preoperative exam as a screening. Ask them to correct the edit. It is also necessary to make sure all documentation supports the use of the consultation code, 99243, (referring physician requested, etc.).

The diagnostic tests should be coded with the diagnosis they are being ordered for. In many states, EKGs will be reimbursed when they are performed for cardiovascular preoperative clearance. The chest x-ray and labs require that medical necessity be met and, therefore, a chronic illness (i.e., hypertension) or symptomatic diagnosis must show medical necessity to be reimbursed. If the tests are performed for screening purposes then the patient must sign a waiver and he or she is held financially responsible. (For more information on waivers, see the article in the April issue of Medical Office Compliance titled Avoid Audit Troubles with Proper Use of ABNS.)


Reader Questions answered by Carol Pohlig, CPC, RN, a reimbursement analyst for the office of clinical documentation in the department of medicine at the University of Pennsylvania in Philadelphia; Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.; Walter J. ODonohue, MD, chairman of the CPT committee of the American College of Chest Physicians (ACCP) and a representative to the AMA CPT advisory committee for ACCP; and Dari Bonner, CPC, CPC-H, CCS-P president/owner, Exact Coding & Reimbursement Inc., Florida