The surgeon’s payment for the global package does in fact include payment for some pre-operative care, the intra-operative service and post-op care. However, medically necessary pre-op evaluations are covered by Medicare and private insurers. A medically necessary pre-op exam might be needed when the patient has cardiac, pulmonary or kidney disease. Some surgeons will routinely send all patients for medical clearance, while others are more selective. Primary care clinicians, cardiologists, and pulmonary physicians perform these services most commonly.
What CPT code and what ICD-9 codes should be reported for these services?
Prior to 2009, Medicare paid for these services as consultations, when the requirements for a consult were met and the service was medically necessary. Currently, Medicare pays for outpatient pre-operative services with new or established patient visit codes, 99201-99215. Some private payers still recognize consults. For those payers, a clinician may bill a consult if there is a request from another healthcare professional (the surgeon) documented in the record, and there is documentation that a copy of the opinion/report was returned to the surgeon. If the conditions for a consult are met, and the payer still recognizes the consultation codes, use 99241—99245. Whether the visit is billed as a new patient, established patient or consult, document the reason for the visit like this, “I am seeing this patient at the request of Dr. Orthopedics for my evaluation of the patient’s medical problems prior to the knee replacement surgery.”
The subjective portion of the note (along with the assessment and plan) should establish the medical necessity of the visit. “Patient here for pre-op” is not sufficient. Document the status of the patient’s medical problems—this is what establishes medical necessity. “She has well-controlled hypertension, without dizziness or chest pain. Her sleep apnea is treated with CPAP, although she is not very compliant with the treatment.” The assessment and plan should support the need for the service, as well.
Don’t bill all pre-op visits at one level
Some physicians bill all of their pre-op visits at one level, which is not correct. The level of service is determined by the complexity of the patient and the type of surgery that is planned. A relatively healthy patient scheduled for a minor procedure in an ambulatory surgery center will need a different level of history and exam than a patient on eighteen medications who is scheduled for general anesthesia.
ICD-9 guidance for pre-op exams instructs clinicians to use an examination code in the first position on the claim form. It says:
“For patients receiving preoperative evaluations only, sequence first a code from category V72.8, Other specified examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.” (V72.8 requires a fourth digit.)
Physician offices are often reluctant to use a V code in the first position on a claim form, preferring to use the medical diagnosis first. Most payers, however, recognize the pre-operative diagnosis in the first position. However, coders should watch for and appeal denials when these services are medically necessary. It would be useful to look at their payers’ policies to make sure that they recognize these codes.
Primary care clinicians and medical specialists can and do get paid to perform pre-op evaluations. Be sure to document the medical necessity for the visit in the history, assessment and plan, then be sure to code pre-op exams appropriately.