pre op visit modifier

The page could not be loaded. The CMS.gov Web site currently does not fully support browsers with "JavaScript" disabled. Please enable "JavaScript" and revisit this page or proceed with browsing CMS.gov with "JavaScript" disabled. Instructions for enabling "JavaScript" can be found here. Please note that if you choose to continue without enabling "JavaScript" certain functionalities on this website may not be available.

An official website of the United States government

Here's how you know

The .gov means it's official.

Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.

The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

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

Document note, note history, contractor information, article information, general information.

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023 , the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act 1862(a)(1)(A)

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

Article Guidance

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.

Response To Comments

Coding information, bill type codes, revenue codes, cpt/hcpcs codes, cpt/hcpcs modifiers, icd-10-cm codes that support medical necessity, icd-10-cm codes that do not support medical necessity, icd-10-pcs codes, additional icd-10 information.

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Other Coding Information

Coding table information, revision history information, associated documents.

• Preoperative
• Postoperative
• Date of Service

Read the Article Disclaimer

Email this document to yourself or someone else

An asterisk ( * ) indicates a required field. This email will be sent from you to the recipient email address(es) you enter. Please do not use this feature to contact CMS. To submit a comment or question to CMS, please use the Feedback/Ask a Question link available at the bottom of every MCD page.

Contractor Detail

Article disclaimer, lcd reference article.

Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).

Articles identified as “Not an LCD Reference Article” are articles that do not directly support a Local Coverage Determination (LCD). They do not include a citation of an LCD. An example would include, but is not limited to, the Self-Administered Drug (SAD) Exclusion List Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article.

Articles which directly support an LCD are known as “LCD Reference Articles” . The referenced LCD may be cited in the Article Text field and may also be linked to in the Related Documents field. Examples may include but are not limited to Response to Comments and some Billing and Coding Articles. If you have a question about this kind of article, please contact the MAC listed within the Contractor Information section of the article.

License Agreements

Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes.

LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT")

End User Point and Click Amendment: CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

You, your employees and agents are authorized to use CPT only as agreed upon with the AMA internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt .

Applicable FARS\DFARS Restrictions Apply to Government Use.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept".

LICENSE FOR USE OF CURRENT DENTAL TERMINOLOGY (CDT TM )

End User License Agreement: These materials contain Current Dental Terminology (CDT TM ), copyright© 2023 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement.

If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen.

If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting.

• Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
• Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org .
• Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use.  U.S. Government Rights Provisions.
• Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license.
• ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for software, including any CDT and other content contained therein, is with CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.
• CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CDT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material covered by this license. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I Accept". If you do not agree to the terms and conditions, you may not access or use software. Instead you must click below on the button labeled "I Do Not Accept" and exit from this computer screen.

LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)

American hospital association disclaimer.

The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Page Help for Article - Billing and Coding: Pre/Postoperative Care: Date of Service (A53472)

Introduction.

This page displays your requested Article. The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections. Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).

Finding a specific code

Some articles contain a large number of codes. If you are looking for a specific code, use your browser's Find function (Ctrl-F) to quickly locate the code in the article. Sometimes, a large group can make scrolling thru a document unwieldy. You can collapse such groups by clicking on the group header to make navigation easier. However, please note that once a group is collapsed, the browser Find function will not find codes in that group.

More information

• Billing and Coding articles provide guidance for the related Local Coverage Determination (LCD) and assist providers in submitting correct claims for payment. Billing and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered.
• Response to Comment (RTC) articles list issues raised by external stakeholders during the Proposed LCD comment period.
• Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. The Medicare program provides limited benefits for outpatient prescription drugs. The program covers drugs that are furnished "incident-to" a physician's service provided that the drugs are not "usually self-administered" by the patient. CMS has defined "not usually self-administered" according to how the Medicare population as a whole uses the drug, not how an individual patient or physician may choose to use a particular drug. For purpose of this exclusion, "the term 'usually' means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage" and the MAC will make no payment for the drug.
• Draft articles are articles written in support of a Proposed LCD. A Draft article will eventually be replaced by a Billing and Coding article once the Proposed LCD is released to a final LCD.

Articles are often related to an LCD, and the relationship can be seen in the “Associated Documents” section of the Article or the LCD. Article document IDs begin with the letter “A” (e.g., A12345). Draft articles have document IDs that begin with “DA” (e.g., DA12345).

Printing a Document to PDF

Frequently Asked Questions (FAQs)

Are you a provider and have a question about billing or coding.

Please contact your Medicare Administrative Contractor (MAC). MACs can be found in the MAC Contacts Report .

Do you have questions related to the content of a specific Local Coverage Determination (LCD) or an Article?

Are you a beneficiary and have questions about your coverage, are you looking for codes (e.g., cpt/hcpcs, icd-10), local coverage.

For the most part, codes are no longer included in the LCD (policy). You will find them in the Billing & Coding Articles. Try using the MCD Search to find what you're looking for. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. The list of results will include documents which contain the code you entered.

Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. All other Codes (ICD-10, Bill Type, and Revenue) have moved to Articles for DME MACs, as they have for the other Local Coverage MAC types.

National Coverage

NCDs do not contain claims processing information like diagnosis or procedure codes nor do they give instructions to the provider on how to bill Medicare for the service or item. For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM).

In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy.

How do I find out if a specific CPT code is covered in my state?

Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. (You may have to accept the AMA License Agreement.) Look for a Billing and Coding Article in the results and open it. (Or, for DME MACs only, look for an LCD.) Review the article, in particular the Coding Information section.

If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. The contractor information can be found at the top of the document in the Contractor Information section (expand the section to see the details).

If you don’t find the Article you are looking for, contact your MAC .

Did you receive a Medicare coverage denial?

Was your Medicare claim denied? Here are some hints to help you find more information:

1) Check out the Beneficiary card on the MCD Search page.

2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. Your information could include a keyword or topic you're interested in; a Local Coverage Determination (LCD) policy or Article ID; or a CPT/HCPCS procedure/billing code or an ICD-10-CM diagnosis code. Try entering any of this type of information provided in your denial letter.

3) Contact your MAC .

4) Visit Medicare.gov or call 1-800-Medicare.

It is Thursday and the weekly MCD data isn’t refreshed?

Are you having technical issues with the medicare coverage database (mcd), mcd session expiration warning.

Your MCD session is currently set to expire in 5 minutes due to inactivity. If your session expires, you will lose all items in your basket and any active searches. If you would like to extend your session, you may select the Continue Button.

Reset MCD Search Data

If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues.

Get the newsletter

Insights for those starting, managing, and growing independent healthcare practices

Get expert tips, guides, and valuable insights for your medical practice

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.

Most Popular

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.

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.

You Might Also Be Interested In

Optimize your independent practice for growth. Get actionable strategies to create a superior patient experience, retain patients, and support your staff while growing your medical practice sustainably and profitably.

Subscribe to The Intake: A weekly check-up for your independent practice

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.

Reviewed by

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.

Suggested for you

Coding rules for modifier 33 and modifier PT

Sample letter for appealing a health insurance claim denial

Leveraging medical record documentation for medical coding accuracy and revenue integrity

Get expert tips, guides, and valuable insights for your healthcare practice, subscribe to the intake.

A weekly check-up for your independent practice — right in your inbox

• Auditing Services
• Coding Services
• Consulting Services
• Provider Education
• Medical Auditing Boot Camp (CPMA Prep)
• E&M Auditing Boot Camp (CEMA Certification)
• Medical Auditing Interactive Workshop
• E&M Resource Center
• Weekly Documentation & Compliance Tips
• Membership Benefits
• NAMAS Lite Membership
• Corporate Membership
• Refer-A-Friend
• Members Only
• NAMAS History
• Content Contributors

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

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!

NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956.  With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.

Looking to start up a medical practice or grow your existing practice? Contact our parent company, DoctorsManagement .

Related posts

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).

Are You Happy With Your Practice Collections ?

Holiday offers for you, helping physician groups to stay profitable.

Contact us today!

Streamline Legacy Accounts Receivable Resolution

Contact Now

Recover your $ which you have left on the table

Request a Quote now

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).

Stuck at medical billing?

Know what are challenges in Credentialing, Charge Entry, Payment Posting, Benefits/Eligibility Verification, Prior Authorization, Filing claims, AR Follow-Ups, Old AR, Claim Denials, resubmitting rejections with Medical Billing Company – Medical Billers and Coders .

We cater to Clinics, Hospitals, and Providers in more than 40 specialties to enhance profitability and boost revenue.

We are the most Professional and expert Medical Billers, who are trained to handle all aspects of Revenue Cycle Management and Denial Management problems, which include:

• Billing service for a group practice with your current software
• Billing for denials
• Credentialing services
• Assistance in handling your AR, Old AR
• Billing Service for Medicaid and Medicare
• Previous billing errors
• Cleaning up claims
• Resubmission of claims
• Possible appeals to maximize your revenue

About Medical Billers and Coders

With expertise spanning over 40 specialties, Medical Billers and Coders (MBC) adeptly manage everything from revenue cycle management to ICD-10 testing solutions. If you’re grappling with billing challenges, look no further – MBC is here to assist.

Reach out today via phone at: 888-357-3226 or email at: [email protected] , and let’s tackle these issues together!

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.

REQUEST A CALL BACK

Are you looking for more than one billing quotes?

• 714-746-3077
• [email protected]

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.

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: 

Medical Billing Modifier Guide

Recent posts.

• Mammogram ICD code and guildelines
• HOW TO Work on Duplicate claim denial – CO 18
• CPT 10009, 10010, 10021 -Fine Needle Aspiration Biopsy –
• CPT Code 0010U ,0011M, 0011U – Infectious Disease (Bacterial)
• CPT code 78451 and 78451 – SPECT guidelines

CPT modifiers update

Recent comments.

• Anonymous on CPT code 99211 – Billing Guide, office visit documentation
• Unknown on Medicare CPT code G0444, 99420 – covered ICD and frequency
• Unknown on CPT 97140, 97530, 97112, 97760, 97750 – Therapeutic procedure
• Anonymous on CPT 95921 , 95922- 95943 – Autonomic function tes
• Saqib_aleeeee on CPT code – 97802, 97803, 97804, G0270, G0271, G0108, dx code

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.

Continue Reading

More in fpm, more in pubmed.

Copyright © 2004 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

• Revenue Cycle Management
• Reimbursement
• Diabetes Awareness Month
• Risk Management
• Patient Retention
• Medical Economics® 100th Anniversary
• Coding and documentation
• Business of Endocrinology
• Physicians Financial News
• Cybersecurity
• Cardiovascular Clinical Consult
• Locum Tenens, brought to you by LocumLife®
• Weight Management
• Business of Women's Health
• Practice Efficiency
• Finance and Wealth
• Remote Patient Monitoring
• Sponsored Webinars
• Medical Technology
• Billing and collections
• Acute Pain Management
• Exclusive Content
• Value-based Care
• Business of Pediatrics
• Concierge Medicine 2.0 by Castle Connolly Private Health Partners
• Practice Growth
• Concierge Medicine
• Business of Cardiology
• Implementing the Topcon Ocular Telehealth Platform
• Malpractice
• Sexual Health
• Chronic Conditions
• Legal and Policy
• Practice Management
• Patient Relations

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

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

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.

2024 Coding Guide: Part 2 - Medicare Advantage

Telehealth's long-term impact on the business of medicine

What you need for better claims management

Finding financing for medical practices

How today’s medical school graduates can start their own practices – even with high student debt

Self-insurance: What practices need to know

2 Commerce Drive Cranbury, NJ 08512

609-716-7777