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Billing and Coding: Pre/Postoperative Care: Date of Service

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CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 40.2 - 40.4

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Where physicians agree on the transfer of care during the global surgery period, the following modifiers are used: •CPT modifier 54 - for surgical care only; or •CPT modifier 55 - for postoperative management only The claim for the surgical care and the claim(s) for the postoperative care must contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier . Appropriate

Inappropriate

The surgeon and the physician(s) providing the postoperative care must collaborate to ensure the appropriate date of service and surgical code are submitted (with the appropriate CPT modifier). Claims are being monitored and will be rejected when submitted inappropriately. For more information regarding global surgery and transfer of care during the global surgery period, refer to the CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 40.2 - 40.4.

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  • Preoperative
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pre op visit modifier

October 25, 2023

Getting Paid

Medical Billing & Coding

Pre-op CPT codes: How to properly code preoperative exams

Mastering pre-op coding is crucial. Here are 5 key practices, from patient clearance to ICD-10-CM codes, to ensure accurate billing and avoid denials.

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At a glance.

  • Not all patients need pre-op clearance; healthy ones usually don’t.
  • Specialists often perform clearance, but surgeons must avoid billing separately.
  • Report 3 ICD-10-CM codes for pre-op clearance, specifying exam purpose.

On the surface, coding preoperative visits is relatively straightforward. Simply choose the evaluation and management (E/M) code that most accurately represents the medical decision-making and patient acuity.

However, there’s more to it than that. Coders need to understand the nuances of reporting these visits if they want to avoid payer scrutiny , says Raemarie Jimenez, vice president, member and certification development, at AAPC . “It’s one thing to go through the steps for good clinical care,” she says. “It’s another thing as to when it’s a billable service.”

Jimenez provides the following 5 best practices to help coders report preoperative visits correctly using pre op CPT (Current Procedural Terminology ) codes and avoid costly denials .

1. Recognize that not every patient requires pre-op clearance 

The purpose of a preoperative visit is to evaluate a patient’s complicating health condition to determine whether they can withstand surgery. Healthy patients don’t generally require a preoperative visit. Surgeons may evaluate healthy patients to determine whether surgery is necessary. However, they don’t typically need to send these patients to a primary care physician, internist, or specialist to clear them for the surgery.

2. Know who can perform pre-op clearance

Specialists and internal medicine physicians are among those who most often perform preoperative clearance because they’re the ones typically managing the conditions that could affect surgery. They are relevant for pre op CPT codes.

“ It’s one thing to go through the steps for good clinical care,” she says. “It’s another thing as to when it’s a billable service.  ”

Surgeons may try to bill these visits without realizing that any preoperative evaluations they conduct after deciding to perform surgery are part of the global surgical package . The global package also includes the visit during which the surgeon performs a preoperative history and physical (H&P). Per CPT guidelines revised in 2016, surgeons can’t bill the H&P separately using modifier -24.

In addition, the global package includes any related subsequent visits that occur prior to the surgery but after the decision. For example, a patient decides to have surgery but then delays for a few months due to scheduling conflicts. The surgeon brings the patient back into the office for an evaluation the day before surgery.

This additional visit is not separately billable, says Jimenez. “The payer says, ‘Okay, we’re paying you for the entire package. Don’t unbundle services we are already paying for,’” she adds. If it’s unrelated to the surgery, it’s separately reportable using a diagnosis that’s also unrelated to the surgery.

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3. Report at least 3 different ICD-10-CM diagnosis codes

 Visits for preoperative clearance require ICD-10-CM codes that denote the following information:

  • Intent for preoperative clearance (Z01.81x)
  • Diagnosis for which the patient is undergoing surgery
  • Diagnosis for which clearance is requested

Note that ICD-10-CM code Z01.81x requires additional specificity regarding the purpose of the preoperative exam (i.e., for cardiovascular exam, respiratory exam, laboratory exam, other preprocedural exam, allergy testing, blood typing, or antibody response exam).

Consider this example: a surgeon sends a patient with acute exacerbation of chronic obstructive pulmonary disease (COPD) to a pulmonologist for preoperative clearance so they can undergo knee surgery to alleviate right knee pain due to osteoarthritis. The pulmonologist should report an E/M code for the office visit as well as the following 3 diagnosis codes (in this order):

  • Z01.811 (encounter for preprocedural respiratory examination)
  • M17.11 (unilateral primary osteoarthritis of the right knee)
  • J44.1 (COPD with acute exacerbation)

The code sequence is important because the Z code indicates to payers that the purpose of the visit is for preoperative clearance, says Jimenez. Note that physicians could report more than one Z code depending on the number of systems they evaluate. When reporting multiple Z codes, also remember to report the additional diagnoses for which the examinations and clearance are required.

 For example, an internist might examine the patient’s COPD and cardiac arrhythmia for preoperative clearance. In this case, report Z01.811 as well as Z01.810 (encounter for preprocedural cardiovascular exam). Then report the ICD-10-CM diagnosis codes that denote the reason for surgery. Finally, report the codes for COPD and arrhythmia. 

Further Reading

4. ensure that documentation supports medical necessity.

To justify medical necessity, documentation should include the following details:

  • Any condition(s) the physician evaluates to clear the patient for the anticipated surgery
  • Whether the patient is cleared for surgery and why
  • Reason(s) the patient isn’t cleared for surgery and any action required for clearance (e.g., prescribe a course of antibiotics to treat congestion)

5. Distinguish between “clearance” and “decision for surgery”

Unlike visits for preoperative clearance that require pre op CPT codes, surgeons can bill for visits to discuss the decision for surgery. Report an E/M code with modifier -57 (decision for surgery) when the encounter is the day before or the day of a major surgery. When the encounter occurs prior to the day before surgery, modifier -57 is not required.

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Lisa Eramo, freelance healthcare writer

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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Aimee Heckman

Aimee Heckman is a healthcare business consultant with more than 25 years of experience in medical practice management, revenue cycle management, PM/EHR implementation, and business development. As a Certified Professional Biller (CBP) and Certified Physician Practice Manager (CPPM), Aimee has demonstrated success in assisting physicians with maintaining their independence and surviving the ever-changing healthcare business environment.

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Pre-Op Visits vs. Pre-Op Clearance Visits: Which are Billable?

pre op visit modifier

August 11, 2023 |  By Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM |  Terry Fletcher Consulting, Inc. | Healthcare Coding and Reimbursement Consultant, Educator and Auditor |  Podcast Host, CodeCast®, NSCHBC Edge Podcast, #TerryTuesday TCG Podcast | NAMAS Educational Speaker and Writer

A question comes up often regarding billing for pre-op visits. Should we? Or shouldn’t we? There is conflicting published guidance on this question from different sources. 

First, this depends on what you mean by “pre-operative visits”. Are you talking about a visit performed by the surgeon (or the surgeon’s QHP) or a provider not involved with the surgery? If the decision is made to perform the surgery during this encounter — whether initial or follow-up — then it is appropriate to report an E&M visit. If the surgery occurs on the same day or the following day, append modifier -57 to the E&M as the decision for surgery modifier. 

However, if the patient is coming in for a “history and physical” or “pre-op” visit to obtain consents and answer questions the patient may have, this encounter is not billable as it is included in the reimbursement for the surgery. In the RVUs for all surgeries with a 90-day global period, there is pre and post-op work included for this encounter. It would be considered “double-dipping” and being paid twice. Many have the opinion that, technically, if this encounter happens two or more days before the surgery, you could bill it, but ethically you probably should not. I would disagree. 

There is no CPT code for a non-billable H&P encounter. Some providers choose to use 99024 to track the frequency and the associated ICD-10-CM codes for these non-billable services. Others use a code they have created, such as pre-op, as a placeholder for these encounters when their EMR allows for it with no dollar figure attached. Other practices don’t track these encounters and may not enter them into the practice management system at all. Now, let’s look at a “pre-op clearance” or surgical clearance encounter that would not be done by the surgeon or the PA/NP practicing under the surgeon. A surgical pre-op clearance is where a specialist (i.e., Cardiologist or Internal Medicine physician) or PCP clears the patient for surgery. For instance, if a patient with CHF (congestive heart failure) is scheduled for a total right knee replacement under general anesthesia, the surgeon and anesthesiologist may request clearance from the patient’s cardiologist. The cardiologist is not performing the surgery and most likely follows the patient for this condition. Therefore, the cardiologist will not be paid for any services included in the global package. The cardiologist should code the pre-operative clearance encounter with the appropriate E&M code and follow the ICD-10-CM guidelines for the encounter. 

These guidelines are in ICD-10-CM General Guidelines: Section IV, Item M “Patients receiving preoperative evaluations only. For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional code. Code also any findings related to the pre-op evaluation.” In the hypothetical case mentioned above, the ICD10-CM codes would be Z01.810, M17.11, I50.9

Another scenario comes up that many coders and physicians attempt to code as a pre-op visit because of the hospital administrative mandate, but you have to determine what the visit is for. Example: Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer: No, the H&P, in this case, is not a billable visit.  This question comes up often and was addressed by AMA CPT® Assistant® in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package. 

Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional questions. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.”

Source: AMA CPT® Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT® says once the decision is made to proceed with surgery, the subsequent visits related to the procedure (e.g., an H&P, getting consent form signed, answering questions) are included in the 90-day surgical package.  However, in some cases, a patient may be a candidate for a surgical procedure but has a number of medical issues (such as cardiac disease, asthma, or Coumadin [anticoagulant adjustment needed]) that require a medical evaluation to determine if he/she is healthy enough for surgery.  After the patient has had a “medical clearance,” he/she returns to you to review the medical doctor’s evaluation, and you, at that point, decide to proceed with surgery.  This visit may be billed as an E&M visit, as the decision for surgery is just now being made.

One thing to remember is that utilizing mid-level providers in a surgery practice, such as a PA or NP, to provide pre-ops is not billable as they are considered the same specialty and are not providing “medical clearance” but a pre-op to reiterate the original encounter discussion with the surgeon. There is no “medical necessity” for billing an administrative visit for duplicate information to get home health referrals, prescriptions, or disability forms signed. You might have a cash charge, but billing this to an insurance company is a red flag. 

Medicare has weighed in on pre-op visits as well:

  • PREOPERATIVE SERVICES A. General.–This manual instruction addresses payment for preoperative services that are not included in the global surgery payment. Sections 4820 and 4821 of the Medicare Carriers Manual (MCM) describe the preoperative care that is included in the global surgery payment. 
  • Non-global Preoperative Services.–Consist of evaluation and management (E/M) services (preoperative examinations) that are not included in the global surgical package and diagnostic tests performed for the purpose of evaluating a patient’s risk of perioperative complications and optimizing perioperative care . Medicare will pay for all medically necessary preoperative services as described in §15047, subsections C and D.
  • Non-global Preoperative Examinations.–E/M services performed that are not included in the global surgical package for the purpose of evaluating a patient’s risk of perioperative complications and to optimize perioperative care . Preoperative examinations may be billed by using an appropriate CPT code (e.g., new patient, established patient, or consultation). 
  • Preoperative Diagnostic Tests.–Tests performed to determine a patient’s perioperative risk and optimize perioperative care. Preoperative diagnostic tests are payable if they are medically necessary and meet any other applicable requirements.

You’ll notice a theme here. CMS is clear that pre-op, whether an E/M visit or diagnostic test, first has to be done to “evaluate the patient’s RISK” for the procedure and then it has to be “medically necessary.” A pre-op that does not address this is not a billable service. It is a routine informed consent visit. 

Your next steps:

  • Contact NAMAS to discuss your organization’s coding and documentation practices.
  • Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
  • Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
  • Check out the agenda for the 15 th Annual NAMAS Auditing & Compliance Conference and register to attend!

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pre op visit modifier

Are You Coding Pre-Operative Clearances Correctly?

Steve Adams, MCS, COC, CPC, CPMA, CPC-I, PCS, FCS, COA

This article will outline the three things we need to see in your documentation when billing a preoperative medical evaluation:

1. Reference to the request for a preoperative medical evaluation

2. The specific medical condition you were asked to address during the preoperative evaluation (e.g. from a cardiovascular or respiratory standpoint); and

3. Proof that you have returned your opinion and advice to the requesting provider.

Prior to 2001, most Medicare carriers were denying preoperative medical evaluations, both examinations and diagnostic tests, on the grounds that they were “routine physical checkups” and thus excluded from Medicare coverage by law. Even carriers who did not deny payment on this basis had conflicting policies about which ICD-9 codes should be used for these claims. Some required physicians to use one of the V codes for preoperative evaluations, some required the codes for the reason for surgery, and still others accepted only codes for comorbid conditions (e.g., hypertension) that necessitated a physician evaluation.

The Present

The purpose of this article is to clarify what the central billing office is requesting from our providers. Medical preoperative examinations and diagnostic tests done by, or at the request of, the attending surgeon should be paid, assuming, of course, that the insurance carrier determines the services to be “medically necessary.”

All such claims must be accompanied by the appropriate ICD-10 code for preoperative examination (i.e., Z01.810 – Z01.818). Additionally, you must document on the claim the appropriate ICD-10 code for the condition that prompted surgery. If there are other diagnoses and conditions affecting the patient, you should also document those on the claim.

Putting It All Together

Let’s say an ophthalmologist requests a preoperative clearance from you for a patient who has diabetes and hypertension and is scheduled for cataract surgery, right eye.

You document the requesting provider’s name and the reason for the preoperative medical evaluation. Then you perform an evaluation and management service and forward a copy of your findings and recommendations to the ophthalmologist clearing the patient for surgery.

When you bill for this service, the primary diagnosis on the claim, and the one attached to the EM code on the line item, will be a Z code (e.g., Z01.818, “Encounter for other preprocedural examination”).

The secondary diagnosis will be the reason for the surgery, the cataract in the right eye (e.g., H25.031, “Anterior subcapsular polar age-related cataract, right eye”).

Finally, if appropriate, you would also code the patient’s diabetes (e.g., E11.9, controlled, type 2 diabetes) and hypertension (e.g., I10, hypertension, benign).

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Correct Coding for Pre-operative Clearance

Pre-operative evaluation and testing services may not be covered under Medicare. Primary care physicians are often asked to evaluate a patient prior to surgery at the request of the surgeon. Patients at an advanced age and those with significant medical problems face increased risk for surgical morbidity and mortality, and preoperative evaluation will depend on the extent of the patient’s condition and the type of surgery.

In fact, medical billing and coding companies are well aware that evaluation and management (E&M) services before surgery can be denied reimbursement if reported incorrectly. Insurance carriers will pay only if they determine the services to be “medically necessary.”

A primary care physician’s preoperative evaluation of a patient scheduled for surgery will include:

  • History – documentation of the past medical history, a review of current symptoms, a list of medications, allergies, past surgical history, and family history
  • Physical exam – height, weight, vital signs, and documentation of any abnormal findings on the exam of the entire body
  • Assessment – a list of medical problems and a plan for each problem identified

Pre-operative clearance:

Medicare does not consider all pre-operative clearance to be medically necessary and will not routinely reimburse these services. Some pre-operative evaluation and testing services may not be covered under Medicare and that coverage and payment are determined by whether or not the service is:

  • A covered benefit identified in the Social Security Act (SSA)
  • Not specifically excluded from Medicare by the SSA, and
  • “Reasonable and necessary” for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, or
  • A covered preventive service

Pre-operative medical evaluation:

According to an article published by the Georgia Academy of Family Physicians in 2016, documentation when billing a preoperative medical evaluation should include the following:

  • Reference to the request for a preoperative medical evaluation
  • The specific medical condition that the family physician was asked to address during the preoperative evaluation (such as from a cardiovascular or respiratory point of view)
  • Proof that the physician has returned his/her opinion and recommendations to the requesting provider.

For example, suppose a patient who has diabetes and hypertension comes in for preoperative examination for carpal tunnel surgery on the right wrist and the surgeon has ordered laboratory tests. The procedures involved are as follows:

  • Document the requesting provider’s name and the reason for the preoperative medical evaluation.
  • Forward a copy of the findings of the evaluation and management service and recommendations to the surgeon clearing the patient for surgery.
  • Assign diagnosis code Z01.812 for the primary diagnosis.
  • The secondary diagnosis should be the reason for the surgery: G56.01, Carpal tunnel syndrome, right upper limb.
  • Code any other diagnoses and conditions affecting the patient related to the preoperative evaluation. For instance, depending on the patient’s condition, other findings to be reported may be E11.9, controlled, type 2 diabetes, and hypertension: I10, hypertension, benign.

A preoperative examination to clear the patient for surgery is part of the global surgical package, and should not be reported separately. You should report the appropriate ICD-10 code for preoperative clearance (i.e., Z01.810 – Z01.818) and the appropriate ICD-10 code for the condition that prompted surgery. All claims for preoperative evaluations should be reported using the appropriate ICD-10 code:

  • Z01.810 : Encounter for preprocedural cardiovascular examination
  • Z01.811 : Encounter for preprocedural respiratory examination
  • Z01.812 : Encounter for preprocedural laboratory examination
  • Z01.818 : Encounter for other preprocedural examination

A recent AAPC blog points out that the primary care physician can bill for the standard preoperative care if the surgeon reduces his package payment. However, Medicare does not support the regular breaking of the surgical package.

Unless geographic distance or other factors prevent the patient from reasonably receiving preoperative care from the surgeon, the preventable extra costs and risks caused in processing two claims (one for the surgeon and one for the primary care physician) would be regarded as abuse by Medicare.

Putting It All Together

Let’s say an ophthalmologist requests a preoperative clearance from you for a patient who has diabetes and hypertension and is scheduled for cataract surgery in, the right eye. You document the requesting provider’s name and the reason for the preoperative medical evaluation. Then you perform an evaluation and management service and forward a copy of your findings and recommendations to the ophthalmologist clearing the patient for surgery.

When you bill for this service, the primary diagnosis on the claim and the one attached to the EM code on the line item will be a Z code (e.g., Z01.818, “Encounter for other preprocedural examination”). The secondary diagnosis will be the reason for the surgery, the cataract in the right eye (e.g., H25.031, “Anterior subcapsular polar age-related cataract, right eye”).

Finally, if appropriate, you would also code the patient’s diabetes (e.g., E11.9, controlled, type 2 diabetes) and hypertension (e.g., I10, hypertension, benign).

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1. How do you code a pre-operative clearance?

To code a pre-operative clearance, use relevant ICD-10 codes reflecting the patient’s condition and reason for surgery.

2. What is the ICD-10 code for pre-operative clearance?

The ICD-10 code for pre-operative clearance falls under Z01.810 to Z01.818, depending on the type of examination.

3. What is the purpose of the Pre-operative assessment?

Pre-operative assessments aim to evaluate a patient’s health before surgery to optimize care and minimize risks.

4. What happens during a medical clearance?

During medical clearance, providers review medical history, conduct exams, and order tests to ensure the patient is fit for surgery.

5. Does Medicare pay for preoperative clearance?

Medicare’s coverage for preoperative clearance varies based on service necessity and coverage policies. Check eligibility before proceeding.

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pre op visit modifier

Pre-Op Visits vs. Pre-Op Clearance Visits: Which Are Billable?

Pre-Op Visits vs. Pre-Op Clearance Visits: Which Are Billable?

A question comes up often regarding billing for pre-op visits. Should we? Or shouldn’t we? There is conflicting published guidance on this question from different sources.

First, this depends on what you mean by “pre-operative visits”. Are you talking about a visit performed by the surgeon (or the surgeon’s QHP) or a provider not involved with the surgery? If the decision is made to perform the surgery during this encounter, whether initial or follow-up, then it is appropriate to report an E&M visit. If the surgery occurs on the same day or the following day, append modifier -57 to the E&M, as the decision for surgery modifier.

However, if the patient is coming in for a “history and physical”, or “pre-op” visit to obtain consent and answer questions the patient may have – this encounter is not billable, as it is included in the reimbursement for the surgery. In the RVUs for all surgeries, with a 90-day global period, there is pre and post-op work included for this encounter. It would be considered “double-dipping” and being paid twice. Many have the opinion that technically if this encounter happens 2 or more days before the surgery, you could bill it, but ethically you probably should not. I would disagree.

There is no CPT code for a non-billable H&P encounter. Some providers choose to use 99024 to track the frequency and the associated ICD-10-CM codes for these non-billable services. Others use a code they have created, such as pre-op as a placeholder for these encounters, when their EMR allows for it, with no dollar figure attached. Other practices don’t track these encounters, and may not enter them into the practice management system at all.

Now, let’s look at a “pre-op clearance” or surgical clearance encounter, that would not be done by the surgeon or the PA/NP practicing under the surgeon. A surgical, pre-op clearance is where a specialist (i.e. Cardiologist or Internal Medicine physician), or PCP, clears the patient for surgery. For instance, if a patient with CHF (congestive heart failure) is scheduled for a total right knee replacement, under general anesthesia, the surgeon and anesthesiologist may request clearance from the patient’s cardiologist. The cardiologist is not performing the surgery, and most likely follows the patient for this condition, therefore, the cardiologist will not be paid for any services included in the global package. So, the cardiologist should code the pre-operative clearance encounter with the appropriate E&M code and follow the ICD-10-CM guidelines for the encounter.

These guidelines are in ICD-10-CM General Guidelines, Section IV item M “Patients receiving preoperative evaluations only. For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional code. Code also any findings related to the pre-op evaluation” So in the hypothetical case mentioned above, the ICD10-CM codes would be Z01.810, M17.11, I50.9

Another scenario comes up, that many coders and physicians attempt to code as a pre-op visit, because of the hospital administrative mandate, but you have to determine what the visit is for.

Example: Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer: No, the H&P in this case is not a billable visit. This question comes up often and was addressed by AMA CPT® Assistant® in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package. Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional questions. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.” Source: AMA CPT® Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT® says once the decision is made to proceed with surgery, the subsequent visits related to the procedure (e.g., an H&P, getting a consent form signed, answering questions) are included in the 90-day surgical package. However, in some cases, a patient may be a candidate for a surgical procedure but has several medical issues (such as cardiac disease, asthma, or Coumadin (anticoagulant adjustment needed)) that require a medical evaluation to determine if he/she is healthy enough for surgery. After the patient has had a “medical clearance” he/she returns to you to review the medical doctor’s evaluation and you at that point decide to proceed with surgery. This visit may be billed as an E&M visit as the decision for surgery is just now being made.

One thing to remember is that utilizing mid-level providers in a surgery practice, such as a PA or NP to provide pre-ops, is not billable as they are considered the same specialty, and again, or not providing “medical clearance” but a pre-op to reiterate the original encounter discussion with the surgeon. There is no “medical necessity” for billing an administrative visit for duplicate information, to get home health referrals, prescriptions, or disability forms signed. You might have a cash charge, but billing this to an insurance company is a red flag.

Medicare has weighed in on pre-op visits as well:

15047. Preoperative Services

This manual instruction addresses payment for preoperative services that are not included in the global surgery payment. Sections 4820 and 4821 of the Medicare Carriers Manual (MCM) describe the preoperative care that is included in the global surgery payment.

B. Non-global Preoperative Services

Consist of evaluation and management (E/M) services (preoperative examinations) that are not included in the global surgical package and diagnostic tests performed for the purpose of evaluating a patient’s risk of perioperative complications and optimizing perioperative care. Medicare will pay for all medically necessary preoperative services as described in §15047, subsections C and D.

C. Non-global Preoperative Examinations

E/M services performed that are not included in the global surgical package for the purpose of evaluating a patient’s risk of perioperative complications and to optimize perioperative care. Preoperative examinations may be billed by using an appropriate CPT code (e.g., new patient, established patient, or consultation).

D. Preoperative Diagnostic Tests

Tests performed to determine a patient’s perioperative risk and optimize perioperative care. Preoperative diagnostic tests are payable if they are medically necessary and meet any other applicable requirements.

You’ll notice a theme here. CMS is clear that pre-op, whether an E/M visit or diagnostic test, first has to be done to “evaluate the patient’s risk” for the procedure, and then it has to be “medically necessary”. A pre-op that does not address this, is not a billable service. It is a routine informed consent visit.

Medical billing cpt modifiers and list of Medicare modifiers.

What is pre – operative visit – common questions

by Lori | Jun 10, 2011 | CPT modifiers

Are the following statements true or false?

• The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules.

• The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery.

• The surgeon can bill and be paid for an office visit for the purposes of a pre-op H&P after the decision for surgery is made, but before the surgery itself, if the hospital requires it.

All of these statements are false!

Let’s take them one by one:

      The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules.

This is false . The primary care provider may be paid to do a medically necessary pre-operative assessment on a Medicare patient prior to surgery, but the visit is billed with a new or established patient visit code. For that matter, a cardiologist or pulmonologist can also bill for these services. The important thing: the visits must be medically necessary for the patient. Routine or screening services are not payable.

     The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery.

This is false. The global surgical payment does include payment for pre-operative services, intra-operative service and post-operative care. The Medicare Fee Schedule includes the percentages for each component for each surgical CPT® code. The pre-operative care is roughly 10%, depending on the service.

When can the surgeon be paid for a pre-op visit?

• For the evaluation of the problem, if the procedure is not done that day or the next day.

• For the evaluation of the problem, if it is a minor procedure with a zero or ten day global period, when the Evaluation and Management service is a significant, separately identifiable service, meeting the criteria for using modifier 25. For example, a gynecologist is asked to see a patient with abnormal bleeding, and decides to do an endometrial biopsy on the same day. Both services may be reported and should be paid.

• For the evaluation of a problem, if it is a major procedure with a 90 day global period, and the physician decides at that visit to take the patient to surgery that day or the next day. If the visit meets the requirements for the use of modifier 57, it is a separately reportable (and payable) service.

There are articles in Codapedia about the use modifier 25 and modifier 57.

        The surgeon can bill and be paid for an office visit for the purposes of a pre-op H&P after the decision for surgery is made, but before the surgery itself, if the hospital requires it.

This is false. Some surgeons believe they can bill for a visit after the decision for surgery was made and before the surgery for the purpose of the H&P, completing the consent forms and educating the patients about what to expect. This is not a separately payable service and should not be billed.

The CPT® Assistant in May of 2009 answered this question specifically. Here is a quote from their newsletter: 

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Getting paid for preoperative and postoperative care needn't be a headache .

KENT J. MOORE

Fam Pract Manag. 2004;11(7):16-17

Family physicians often find themselves collaborating with surgeons when their patients need surgical procedures they don’t provide. Because Medicare and other payers bundle payment for the various services associated with a surgery into a single payment (see “Spanning the Global Surgical Package,” FPM, September 2003, page 18 ), family physicians are sometimes confused about how to bill for their services when a patient undergoes surgery. This article attempts to eliminate some of that confusion.

Office visit vs. preoperative consultation

Prior to surgery, the surgeon may send your patient to you for preoperative clearance. This generally occurs when the patient has comorbid conditions (e.g., hypertension or diabetes), and the surgeon is otherwise concerned about the patient’s fitness for the procedure. In this situation, it is appropriate to submit a consultation code for the preoperative clearance, as long as the service meets the definition of a consultation. According to the CPT manual, a consultation is “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” In the case of a preoperative clearance, a surgeon is typically requesting your opinion or advice regarding the patient’s fitness for surgery.

To code a consultation for this service, you must document the surgeon’s request, your advice and any services ordered or performed; you must also provide a written report to the surgeon. Keep in mind that consultation codes apply to both new and established patients. If you provide other preoperative services during the consultation (e.g., an ECG), you should code for those services too.

When billing Medicare for a consultation, be sure you also submit the appropriate diagnosis codes. Choose a code from the V72.81-V72.84 series (preoperative exams) as the primary diagnosis. The secondary diagnosis should be the reason for surgery. Any other diagnoses and conditions affecting the patient (e.g., the specific problem evaluated) should be listed as the third and subsequent diagnoses. Although other payers may follow the same convention as Medicare, some may require the relevant diagnoses in a different order (e.g., the condition prompting the consult first).

You may also want to have your Medicare patients sign an Advance Beneficiary Notice (ABN) if you think the service may be denied for lack of medical necessity (see “Using Advance Beneficiary Notices to Maximize Your Medicare Collections,” FPM, September 2002 ). This will permit you to bill your patients directly if Medicare denies payment.

When a preoperative clearance does not meet the definition of a consultation, simply code the encounter using an office or other outpatient visit code (99201-99215). For example, a patient presents with a history and physical form that the hospital needs and you provide the history and physical. In this scenario, it is not clear that the patient’s surgeon has asked for your advice or opinion regarding evaluation or management of a specific problem. Since this is a prerequisite for using a consultation code, this visit doesn’t meet the definition of a consultation. Submit an office or other outpatient visit code (e.g., 99214) instead, depending on the level of history, exam and medical decision making involved. If you have any questions about whether the surgeon is requesting a consultation, contact the surgeon to clarify the situation.

Coding for the hospital admission

The work of the hospital admission is generally considered to be included in the global surgical package. As such, it is generally the surgeon’s job to admit the patient to the hospital for the procedure and perform the associated history and physical. However, in the case of an itinerant surgeon or a patient admitted for medical problems that subsequently require surgery, you may be the one who admits the patient and does the associated history and physical. In this case, you should bill for the admission using the appropriate initial hospital care code (99221-99223).

Assisting with surgery

Sometimes you may be asked to assist with a surgical procedure. To code for this, you should add modifier -80, “Assistant surgeon,” to the surgical procedure code. For example, you may be asked to assist with a hysterectomy on an obese patient. In this case, use code 58150-80. Payers will typically pay physicians assisting with surgery a percentage of the fee otherwise paid for the global surgical service. For example, the Medicare fee schedule amount equals 16 percent of the amount otherwise applicable for the global surgery.

Postoperative care

The global surgical package includes payment for typical postoperative care. The surgeon who performed the surgical procedure is generally presumed to be providing the postoperative care.

In some situations, however, you may be involved in the postoperative care. For example, a patient who underwent hip replacement surgery may develop cardiac problems that the orthopedic surgeon is not comfortable handling. If the surgeon asks you to assume responsibility for the patient’s care, you should code your services using the appropriate subsequent hospital care and office visit codes (99231-99233 and 99201-99215, respectively). If the surgeon simply requests your advice about how to manage the problem and you document this request and provide your advice in writing to the surgeon, you should code these services using the appropriate consultation codes (99251-99255 and 99261-99263 for inpatients; 99241-99245 for outpatients).

Be aware, however, that Medicare and many other payers will not reimburse you for both a preoperative and a postoperative consultation on the same patient for the same episode of care. If you’ve provided a preoperative consultation and the surgeon calls you in for a postoperative consultation on the same patient, you will need to code your services using either a subsequent hospital care or office visit code, depending on the site and service.

You may also find yourself providing postoperative care for a patient who has had surgery outside your local community. In this situation, it may be unfeasible or impractical for the surgeon to provide the typical postoperative follow-up care. If you provide the typical postoperative care instead of the surgeon, you should bill your services by appending modifier -55, “Postoperative management only,” to the code for the surgical procedure. Using the hip replacement example above, you would bill your postoperative services using 27130-55. To indicate that the surgeon did not provide the global surgical service in this circumstance, he or she should report the surgical code with modifier -54, “Surgical care only,” attached.

Note that for Medicare and some other third-party payers, coding postoperative follow-up care with modifier -55 implies a transfer of care from the surgeon to you. Where a transfer of care does not occur, Medicare and other payers may require the occasional postoperative services of a physician other than the surgeon to be reported with the appropriate E/M code.

When you are providing all or part of the typical postoperative follow-up care, it is a good idea to contact the patient’s insurer to verify how your services should be billed. Before coding postoperative follow-up care with modifier -54, it is also a good idea to communicate with the surgeon’s office to coordinate your respective claims so you both use the same surgical and diagnosis codes and so they don’t bill the service globally.

Coding and billing for your services when you are the only one involved is tough enough. Doing so when a surgeon is also involved makes it that much tougher. However, it’s worth the effort to learn how to code for these services so you are appropriately paid for the work you do.

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How to code global surgery modifiers 54, 55, and 56 the right way

Understand the proper use of modifiers 54, 55 and 56.

coding modifiers

Question: Can you tell us the proper use of modifiers 54, 55 and 56?

Answer: To understand these modifiers, we first need to review the surgery global period.All medical procedures that include a global period are made up of three parts, explained in more detail later in the article:

  • pre-operative services
  • intra-operative services, and
  • post-operative care.

If a physician does not perform all three parts of the service, compliant coding dictates that you append modifier 54  Surgical care only , modifier 55  Post-operative management only , and the less-used modifier 56 Preoperative care only , as appropriate.

The “Global” Concept

The Centers for Medicare & Medicaid Services (CMS) and other payers “bundle” services typically related to a surgical procedure into reimbursement for that procedure. The resulting global surgical package includes all “necessary services normally furnished” by a provider “before, during, and after a procedure,” as defined by CMS. The global concept applies in any setting (e.g., inpatient hospital, outpatient hospital, ambulatory surgical center, physician office, etc.).

According to Medicare’s Global Surgery Booklet , the following services are included in the global surgery payment:

  • Pre-operative visits after the decision is made to operate. For major procedures, this includes pre-operative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
  • Intra-operative services that are normally a usual and necessary part of a surgical procedure
  • All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room
  • Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
  • Post-surgical pain management by the surgeon
  • Supplies, except for those identified as exclusions
  • Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

Services  not  part of the global package include visits unrelated to the diagnosis for which the surgical procedure is performed, diagnostic tests and procedures, critical care services, and post-operative treatments that require a return to the operating room, among others listed in MLN Global Surgery Booklet.

Although CMS, private payers, and the CPT® codebook all embrace the global package concept, they do not agree on what that package includes.In this article, we will cover Medicare rules. Be sure to check with each of your payers for their policies.

Billing the Global Package

Those procedures with a 10-day or 90-day global period are assigned separate values for pre-procedure, intra-procedure, and post-procedure reimbursement. You can find these valuations in the Medicare Physician Fee Schedule . The columns labeled “PRE OP,” “POST OP,” and “INTRA OP” list the percentage value that Medicare will reimburse for only that portion of the procedure (the total of the three columns is 1.00).

When a healthcare provider performs a surgery, including all usual pre-and post-operative care, they may report that procedure using the appropriate CPT® code for the surgical procedure, only. Do not separately bill for visits or other services included in the global package.

When components of a global surgical procedure are furnished by different providers, each provider is expected to report only the service they performed and identify that service with the appropriate modifier and with the surgery date listed as the date of service. Indicate elsewhere on the claim the date care was relinquished or assumed. Where a transfer of postoperative care occurs, the receiving physician providing the postoperative follow-up care may not bill for any part of the global services until after he/she has seen the patient for the first postoperative visit/service.

Modifier 54 Surgical care only : When one physician or other qualified health care provider (QHCP) performs a surgical procedure and another provider performs the pre-operative and/or post-operative management, surgical services may be identified by adding modifier 54 to the usual procedure code.Modifier 54 indicates that the surgeon is relinquishing all, or part, of the post-operative care to another physician or QHCP.

Modifier 55 Post-operative management only : This modifier is billed by the receiving physician, other than the surgeon, who accepts the transfer of care and furnishes post-operative management services.

A surgeon may not report both modifier 54 and modifier 55 for the same surgical procedure. The use of modifier 54 indicates the surgeon has transferred postoperative care (partial or total) to another provider, and the surgical code with modifier 55 appended will be billed by the receiving provider to whom the postoperative care was transferred.

Modifier 56 Preoperative care only : This modifier is billed by the surgeon who only performs the pre-operative management services.

‘Split-care’ modifiers 54, 55, and 56 are only valid with surgical procedure codes having a 10- or 90-day global period.

Transfer of Care

If the provider who performs the surgical procedure, only (e.g., the “intraoperative” portion of the service), and does not furnish the follow-up care, the post-operative care is paid separately if the provider who performed the surgery and the provider who performs the post-op care agree on a transfer of care.

The provider who performed surgical care should append modifier 54 to the appropriate CPT® code(s) to describe the surgery performed. Per CMS, the modifier signals that the surgeon intends to transfer “all or part of the post-operative care” to another provider.

The physician who provides post-operative care should report the same code(s) as the surgeon, but with modifier 55 appended. The physician should not bill until they have provided at least one service. CMS advises, “Report the date of surgery as the date of service and indicate the date that care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.”

For example, an emergency department physician may reduce a fracture and place a cast. Per a transfer of care agreement, the patient later follows-up with their family physician. The ED physician would report the appropriate fracture care code(s) with modifier 54 appended. The family physician would report the same code(s), but with modifier 55 appended.

Per Medicare rules, “Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.”

In summary : When appending modifier 54 or modifier 55, you must coordinate your coding with that of the physician who provides the other portion of care. Failure to cooperate in this way will likely result in one physician (usually the physician who provides postoperative care) missing out on reimbursement.

When Not to Use 54 and 55

CMS allows exceptions to the use of modifiers 54 and 55 for follow-up services during a post-operative period in the following circumstances:

Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim.

Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier.

If the services of a physician, other than the surgeon, are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient. For more information, refer to the Medicare Claims Processing Manual,  Chapter 12 , Sections 40.2 and 40.4.

Renee Dowling is a compliance auditor for Sansum Clinic, LLC, in Santa Barbara, California.

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