Coding Consult

Nailing down pre-op clearance exams

Proper documentation enhances your chances of getting paid.

Just because a surgeon refers a Medicare patient to you to get a go-ahead before surgery, don't think you're guaranteed payment. You'll need to prove that the exam was medically necessary, and you'll have to comply with Medicare's rules. To be safe, you should have the patient sign an advance beneficiary notice before the exam in case Medicare denies the claim.

A denial is very likely, in fact, unless the patient has a chronic disease that could affect his ability to withstand surgery or the surgeon wants a recommendation on medication changes before, during, or after the surgery.

Code the visit as a consultation using the appropriate office/outpatient code (99241-45) or, if the patient is in the hospital, the appropriate initial inpatient consultation code (99251-55).

To qualify as a consultation, the visit must include the "three Rs," notes Barbara Holley, coding supervisor at the Stuart, FL-based Martin Memorial Medical Group, which has more than 50 physicians. You must receive a Request for an opinion, document the Reason for the request (the patient's chronic illness), and generate a Report. The request from the surgeon doesn't have to be in writing. However, you must document the evaluation in the patient's chart and send a written report to the surgeon.

Jan Rasmussen, president of the Eau Claire, WI-based Professional Coding Solutions, says some primary care doctors are reluctant to use the higher-paying consultation codes for pre-op exams if they have seen the patient recently for an office visit. However, the consultation codes are proper when the surgeon requests advice or an opinion.

Holley says many doctors find it easy to dictate the report as part of their office notes after seeing the patient. Just be careful that you don't suggest you're assuming care of the patient.