American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to bill Medicare for a pre-operative assessment

By Brett Baker

Q: When does Medicare cover pre-operative services to help determine a beneficiary's fitness for surgery?

A: Medicare typically pays for a non-operating physician's pre-operative services that assess a beneficiary's fitness for surgery.

The Centers for Medicare and Medicaid Services (CMS), formerly HCFA, has specified the conditions under which pre-operative services are covered because in the past, certain Medicare carriers had denied payment for them. Carriers had inappropriately labeled these services "routine and preventive" or decided that payment for them was already included in the global surgical period fee the operating surgeon receives. The Medicare global fee encompasses services provided by the operating surgeon the day before an operation (or the day of for minor procedures) through a specified number of days after the surgery.

Medicare-covered pre-operative services consist of evaluation and management (E/M) services that are not included in the global surgical package, as well as diagnostic tests to evaluate the risk of complications and optimize perioperative care.

ACP-ASIM was instrumental in alerting CMS that certain Medicare carriers were inappropriately denying claims for necessary pre-operative services. The CMS policy clarification mirrors College recommendations.

Q: How should I code pre-operative visits and tests?

A: Bill for pre-operative evaluations using the appropriate Current Procedural Terminology (CPT) code (new patient, established patient or consultation). Pre-operative evaluations often qualify as consultative visits. You can bill a consultation if a surgeon asks you to evaluate a patient's fitness for surgery-even for one of your established patients-if you meet the following criteria:

  • offer an opinion or advice to the requesting physician and document your opinion;
  • make a treatment options decision;
  • perform or order distinctive diagnostic or therapeutic procedures and document them; and
  • send a written report detailing your opinion and any diagnostic/therapeutic services to the requesting physician.

Medicare requires that you justify pre-operative visits and tests using a diagnosis code that indicates the type of preventive examination and the condition(s) that prompted the surgery. You should select your primary diagnosis from the following ICD-9 codes: V72.81 (pre-operative cardiovascular examination), V72.82 (pre-operative respiratory examination), V72.83 (other specified pre-operative examination), V72.84 (pre-operative examination, unspecified).

List the ICD-9 code indicating the reason for the surgery as the secondary diagnosis. Include on the claim additional diagnoses (or other information) relevant to the pre-operative service(s).

Case study

A general surgeon asks you to determine whether one of your established patients, a 75-year-old female, is able to withstand the general anesthesia required to remove a cancerous colon tumor.

You evaluate the patient in your office, performing a history and physical examination, and pay special attention to her cardiovascular system because she has a history of aortic stenosis. You also order and perform a routine electrocardiogram (ECG) and write a report after interpreting the findings.

You conclude that the anesthesia poses minimal risk to the patient and that the benefit of the surgery exceeds the risks. You send a written report detailing your findings, including recommendations regarding antibiotic prophylaxis, to the operating surgeon.

You would bill Medicare for the appropriate office consultation code and the ECG justifying the pre-operative services according to Medicare's ICD-9 coding requirements. The claim should include:

  1. The appropriate office consultation code, selecting from CPT 99241-99245, and ICD-9 code V72.81 (pre-operative cardiovascular examination to justify the consultation).
  2. CPT code 93000 (ECG with at least 12 leads, interpretation and report) and ICD-9 code V72.81 (pre-operative cardiovascular examination to justify the ECG).
  3. ICD-9 code for colon cancer to explain the reason for the surgery. Use stenosis, a condition complicating the surgery, as supporting justification. Use ICD-9 153.9 (malignant neoplasm, colon) and ICD-9 424.1 (aortic valve disorder-stenosis).

Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, contact him at 202-261-4533, or bbaker@acponline.org.

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