Maybe this will help explain this to your physician:
Coder Pink Sheets: Medical Practice Coding Pro
Preop H&P not separately billable, CPT confirms
Coder Pink Sheets: Medical Practice Coding Pro » Medical Practice Coding Pro: Medical Practice Coding Pro, November 2009, Vol. 15, No. 11
Effective Nov 1, 2009
Published Nov 1, 2009
________________________________________
Your physician has already made the decision for surgery and the date for the procedure is set. The patient comes in a few days in advance of surgery for a history and physical (H&P), consent signing and to answer a few final questions.
A billable service?
No, it is not.
CPT confirmed this policy in a clarification of its coding guidance issued recently:
"If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package," (CPT® Assistant, May 2009).
CPT further cites the following example: "The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional questions. This visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package."
That squares with longstanding Medicare policy. For major surgeries, the global period actually begins 24 hours in advance of the date of the procedure, then continues for 90 days after, according to Medicare rules (Medicare Claims Processing Manual, 100-04, Chapter 12, Section 30.6.6).
Often, Medicare allots 20% of a surgical code's work relative value units (RVUs) for preop work. (See Medicare's physician fee schedule relative value file for the break out by code.)
And no, it's never a good idea to game the system and schedule a preop H&P more than 24 hours prior to surgery just to get it paid. CPT Assistant confirms in the policy above that such a practice goes against AMA coding rules.
Hospital policies may conflict: One source of confusion is that your hospital may be telling you that preop H&Ps are required under its policies. That may be true, but it doesn't mean you can bill for the service. Explain to your physicians they are already getting paid for the H&P as a component of the surgical code.
When a visit is billable: Note that the E/M visit when the decision for surgery is made would still be separately reportable - even if it occurs the day before or the day of the procedure, as with a trauma or injury patient, CPT reminds: "If the decision for surgery occurs the day of or day before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone" (CPT Assistant, May 2009).
If a patient has underlying medical conditions not directly related to the surgery (e.g., diabetes, coronary artery disease or hypertension), a preoperative consultation may be medically necessary to clear the patient for surgery. That service may be performed by the patient's primary care physician or a hospitalist, or by the appropriate specialist (e.g., a cardiologist may consult on a patient's congestive heart failure).
Bottom line: Once the decision for surgery has been made, the decision to report a preop exam must be made on a case-by-case basis. If there's no medical necessity, it's likely the visit is not separately billable.
Official resources:
CPT Assistant, May 2009
Medicare Claims Processing Manual, 100-04, Chapter 12, Section 30.6.6:
www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
Medicare physician fee schedule relative value file:
www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage
Preop Scenarios: Check your knowledge
Here are some typical preoperative exam examples. Test your knowledge of whether these scenarios would be separately billable or not:
1. A patient with high blood pressure and a history of coronary artery disease is scheduled for elective knee replacement. Prior to admission, the surgeon requests a cardiologist clear the patient for surgery, in light of chronic conditions. Would this visit be:
• a. billable
• b. not billable
2. An orthopedic surgeon sees a patient with a fracture in the emergency room and determines open reduction is needed that day.
• a. billable
• b. not billable
3. During an office exam, an ObGyn determines an otherwise healthy patient requires a hysterectomy. Surgery is scheduled three weeks later. Two days before the procedure, the doctor sees the patient once more for a quick H&P, to answer last minute questions and to get the consent agreement signed.
• a. billable
• b. not billable
4. Otherwise healthy patient is admitted for a planned surgery. Hospital requires H&P within 24 hours of admission. Attending surgeon requests a hospitalist provide this service.
• a. billable
• b. not billable
5. Patient with unstable diabetes is admitted for a foot amputation. Surgeon asks a hospitalist to manage the patient's diabetes prior to surgery.
• a. billable
• b. not billable
Answers: 1. a., 2. a., 3. b., 4. b., 5. a.