Wiki pre-operative physicals

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mrolf

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What is the correct way to code a non-medicare patient who comes in to the Primary care physician for a pre-op physical requested by the surgeon for clearance for surgery, but the patient is a normal healthy person with no problems other than what is having surgery for (knee scope). We have been billing a problem visit (ex:99214). Is this acceptable. I always receive conflicting answers. The surgeon is getting paid for the pre-op care but the guidelines say (preop physical the day prior or day of surgery). The primary doc is doing this a week to 2 weeks prior to surgery. The surgeon and the primary care physician feel that the family doctor who knows the patient better than the surgeon should be the one to do the pre-op and clearance for surgery. The surgeon says we do not know the patient like the PCP does.
If anyone can give me a definitive answer I can bring to the administrative team would be helpful. T
 
A pre-op clearance visit requested by the surgeon should be coded as a consultation by the PCP. The primary dx code would be V72.8X, followed by the reason for surgery (ie 715.16) followed by any co-morbidities (ie 250.00, 401.9, etc). There must be a request for the service as well as a report back to the surgeon either clearing or not, and any post op recommendations for medications, etc.
 
It really should not be coded as a consultation, this patient is not being requested to be seen in consultation by his PCP, the PCP is being requested to provide a pre operative evaluation of the their own patient, it really does not meet the criteria of a consult. So it should be coded as an office encounter.
 
-56 modifier

Actually it should be coded with the same procedure code the surgeon will be using and a -56 modifier. The PCP is being asked to provide the preoperative management of this patient.

The surgeon should not get paid for services s/he is not going to perform. So the surgeon should code the procedure with -54 modifier.

F Tessa Bartels, CPC, CEMC
 
Oh I so agree with you Tessa and I teach it that way to my classes. However as the above scenario was so far out from the pro op global I was not not sure if that was still appropriate. But for the record I think they should all be billed with the 56 modifer.
 
I agree with Debra and Tessa, but I need a little further clarifacation, please. Let's say the patient comes in to see his/her PCP because they have CAD and the are scheduled for open heart surgery of some kind. The PCP examines the patient and runs labs et all to determine that the patient is OK for the surgery. We would code this with the procedure code for the heart surgery with -56, correct? What about the E/M? This would be bundled into the procedure correct?

What about the ICD-9 codes? It would be the V code for the preop exam and the code for the CAD?

I think confusion is that the surgeon is sending a request for the preop clearance to the provider and the provider is sending it back with the OK for the surgery. I think that most people are seeing this as the three R's for the consult.

Thanks
 
You are correct there is no separate E&M as it is the pre op management covered by the 56 modifier. And it is the V code followed by the dx for the surgery. I know most people THINK the 3 Rs have been met but really they have not. The requesting physician (surgeon) is not requesting a consult, they are asking for a medical status report they are not requesting a decision or opinion they simply want a status so no consult.
 
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according to Arizona's Medicare guidelines, you cannot report a preop visit as a consult nor an E/M without medical necessity. The surgeon must identify a risk factor for surgery that the pcp is requested to evaluate. That is the true meaning of clearance. For example, an ortho requests a pcp to evaluate his patient for knee surgery because of his high blood pressure. the pcp's CC is hbp and he evaluates the patient only for that DX and sends a report back to the surgeon (99241-99244). the pcp's primary DX is HBP, not the knee pain or any other v codes. You cannot default to est (99212-99214) because they also require medical necessity and routine screenings for labs, ekg or xrays are not considered as medical necessity and therefore are not payable. The pcp could perform a PM if patient agrees, otherwise, these type of visits should not be even scheduled. The surgeon should send routine tests to hospital, for example because he's his surgery pmt includes preop testing;you need to check with your state's Medicare provider for details...
 
I think loptas brings up a good point. If the patient is otherwise healthy, why is clearance needed? If there is medical necessity for a visit, it could be a consult if the surgeon is requesting the advice from the PCP (as in the HBP example above). I would not consider it to be part of the pre-op global package because the PCP is not doing the pre-op if his advice is being sought.

Good question and debate!
 
We too are looking into this and I'm so glad the modifier 56 was mentioned. I was trying to find some guidance in how it should be reported, as CMS IOM only provides direction for use of the 54/55 modifiers. Sounds like it should be applied to the surgical procedure code, is that correct? We have NPP's providing the required pre-op anesthesia clearance for dental surgeons, since I'm told it is not w/in their (dentists) scope of practice to provide the h&p. I agree that the NPP's should not being billing an E/M visit for this (consult or outpt visit), since a preop h&p is considered part of the global payment.
 
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