Coding for a primary care preoperative exam

Q: What CPT code should be used for proper coding of a preoperative visit by a primary care physician, and does the place of service (office versus hospital) make a difference?

The appropriate documentation requirements for a consultation must be met to bill these codes: request for a consultation (that is, clearance for surgery for the specific condition[s] that might cause complications with the surgery), documentation of the PCP’s visit (to substantiate the level of code billed), and a separate letter back to the surgeon detailing the findings. If these elements are not met, the appropriate established E/M code would be billed, 99211-99215.

These PCP preoperative exams normally are performed in an office setting, even when the surgery is performed in the hospital. This is routine and should not cause any "red flags" to the carrier.

Renee Stantz is a compliance manager for Baptist Medical Associates in Louisville, Kentucky. Have a coding or managed care question for our experts? Send it to meletters@advanstar.com
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