Proper documentation enhances your chances of getting paid.
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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.
Internist Bruce Rappoport, who works with physicians on compliance, documentation, coding, and quality issues for RCH Healthcare Advisors in Fort Lauderdale, suggests that the primary care physician provide a copy of the report to the surgeon's office and to the hospital where the surgery will be performed.
The key to receiving payment for the pre-op evaluation is to show medical necessity. To accomplish this, document the patient's illnesses and select the proper codes for primary and secondary diagnoses. Many physician offices use the reason for surgery (e.g., broken hip) as the primary diagnosis, Holley notes, but Medicare has specifically said that the reason for surgery should not be used as the primary diagnosis.
Instead, Medicare has stated that doctors should use the V72.81-84 series as the primary diagnosis for all pre-op clearance examinations. Use V72.81 for a cardiovascular exam, V72.82 for a respiratory exam, V72.83 for a specified other exam, and V72.84 for an unspecified exam.
Holley says the latter two codes are rarely used. For example, Jan Rasmussen says, use V72.83 when the patient has a chronic disease that is not respiratory or cardiac, say kidney disease. Use V72.84 for a routine pre-op when the patient has no underlying conditions.
Other diagnoses and conditions affecting the patient may also be documented, if appropriate, says Medicare. For instance, when a patient with chronic hypertension and diabetes has a pre-op in advance of surgery for a broken hip, V72.81 is the primary diagnosis. Next, use the codes for the patient's other chronic conditions as secondary diagnoses: 250.00 (diabetes mellitus without mention of complication; type II . . .) and 401.9 (essential hypertension; unspecified). The reason for surgery should appear only after the primary and secondary diagnosis codes.
In the absence of a national policy, says Medicare, carriers have the discretion to decide whether preoperative evaluation services are "reasonable and necessary" and that such a decision will be "facilitated" if the ICD-9 codes denoting the reason for the surgery and the reason for the pre-op are included as diagnoses on the claim.
Rasmussen notes that a national policy has not been set on which diagnosis codes are covered for preoperative exams. Ask your local carrier for specific guidelines.
Patients with chronic illnesses such as diabetes or heart disease, especially those who are on medication that must be adjusted prior to surgery, will generally meet the criteria for "medical necessity" for a pre-op exam.
Rappoport gives the following example: A surgeon requests a pre-op evaluation from you on a patient with chronic atrial fibrillation who is on the anticoagulant drug Coumadin. Your report discusses the physical you perform and history you take, and assesses the patient's fitness for surgery. You also make recommendations concerning the patient's medications before, during, and after surgery. In this case, you provide specific instructions concerning the anticoagulant, such as recommending that the patient's Coumadin be discontinued three days before the surgery and providing a timeframe for the start of IV heparin.
Code the visit using the appropriate consultation level, with a primary diagnosis of V72.81. Secondary diagnoses that document the medical necessity of the pre-op exam are 427.31 (cardiac dysrhythmias; atrial fibrillation) and V58.61 (long-term [current] use of anticoagulants).
Coding for patients with less definitive problems is more difficult. For example, take the patient who has a history of asthma but has had no recent problems and is not on medication. Use the appropriate consultation code (e.g., 99243) with V72.82 as the primary diagnosis and 493.90 (asthma, unspecified, without mention of status asthmaticus or acute exacerbation or unspecified) as the secondary diagnosis. Because the asthma is not being actively treated, however, it's questionable whether carriers would consider the pre-op evaluation medically necessary.
Finally, Rappoport says, you'll have difficulty documenting medical necessity on a healthy, athletic patient having minor surgery. If the patient does not have a chronic disease, the preoperative evaluation that most hospitals require before surgery is generally performed by the surgeon and bundled into the global surgical package.
This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Rd. South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.
Coding Consult: Nailing down pre-op clearance exams. Medical Economics 2002;19:31.