Wiki Preop clearance Help

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When coding a cardiology pre op clearance is there any specific criteria to be met or are we to follow the regular documentation guidelines, i.e. consult 99243 etc.? I have an issue where there is really no HPI. It only states insulin dependend diabetic, dyslipidemic, hypertensive & hypothyroidism. No chest pain,shortness of breath or syncope.

All other areas met for exam and mdm.

I also have one other question unrelated to pre op clearance. When performing comprehensive exam, documentation requirements state - perform all elements in at least 9 organ systems/areas but then it states you only have to document 2 elements from each?
Seems strange to only have to document part of what is done?

Thank you,
Deb
 
CBC said:
When coding a cardiology pre op clearance is there any specific criteria to be met or are we to follow the regular documentation guidelines, i.e. consult 99243 etc.? I have an issue where there is really no HPI. It only states insulin dependend diabetic, dyslipidemic, hypertensive & hypothyroidism. No chest pain,shortness of breath or syncope.

All other areas met for exam and mdm.

I also have one other question unrelated to pre op clearance. When performing comprehensive exam, documentation requirements state - perform all elements in at least 9 organ systems/areas but then it states you only have to document 2 elements from each?
Seems strange to only have to document part of what is done?

Thank you,
Deb
Click to expand...

A. You can't bill for pre-op clearance E/M - it's bundled into the surgery. Only the decision for surgery, or a significant and separately identifiable E/M service is reportable (Like an unrelated E/M, or an acute complication that suddenly came up before the surgery). Sorry... :(

B. Under 1997 guidelines, for a comprehensive multi-system exam, you have to document a minimum of 18 bullets from at least 9 different organ systems. (2 bullets from each system). The doctor is supposed to perform all elements with a bullet within 9 different OS, but apparently he only has to write down the results from 2 of the bullets in each section. Yes, it is strange, but it's probably meant to avoid lots of redunant entries of "normal" findings in each system. I don't know how you'd prove that all of the elements were performed without documenting it, but I guess nobody's checking...kind of a stupid rule, really. :rolleyes: Hope that helps!:D
 
Brandi, thank you very much for responding. I did not make myself very clear on the pre op exam. This is the cardiologist doing the pre op for lumbar surgery. Any advise?
 
CBC said:
Brandi, thank you very much for responding. I did not make myself very clear on the pre op exam. This is the cardiologist doing the pre op for lumbar surgery. Any advise?
Click to expand...

Check out this article:
http://www.aafp.org/fpm/2004/0700/p16.html

It'll depend largely on whether your patient has Medicare or not, and if they don't, whether the visit meets the requirements of a "consult" versus an outpatient exam. ;)
 
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