Family physicians are frequently asked to perform pre-surgical evaluations, both in the office and at the hospital. The Centers for Medicare & Medicaid Services recently proposed no longer requiring a comprehensive medical history and physical assessment prior to surgery, but many patients will still need an evaluation and many surgeons will still request one.
Physicians must select a CPT code and a diagnosis code for the evaluation. This is typically done in the office for scheduled procedures and in the hospital for urgent or emergency surgery.
CPT codes. If the evaluation meets the requirements for a consultation, and if the patient’s insurance company still recognizes consultation codes (many commercial payers still do), you can bill a consult. Consult codes most accurately describe the service performed and are reimbursed at a higher rate than new and established patient visit codes. According to CPT, “A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.” Use outpatient codes 99241-99245 or inpatient codes 99251-99255 for new or established patients.
Like most evaluation and management codes, consultation codes have different levels that require performance and documentation of a certain level of history, exam, and medical decision-making as part of the encounter. If you perform and document the key components, and if the medical record reflects the request for evaluation and that you returned a report to the requesting physician, you should have no difficulty reporting a consultation code for the encounter, as long as the payer accepts consultation codes.
Medicare and Medicare Advantage plans do not recognize consult codes. State Medicaid programs and Managed Medicaid plans can also set their own rules and may not recognize consult codes. For these patients seen in the office, bill a new or established patient office visit code (99201-99205 or 99211-99215), and for inpatients bill the appropriate hospital care code. You can typically bill an initial hospital service (99221-99223). The admitting physician typically uses an AI modifier (Principal Physician of Record) on the initial hospital care code to indicate that he or she is the admitting physician, and consultants typically use the initial hospital care code with no modifier.
Diagnosis codes. For the diagnosis, use a code from subcategory Z01.81-, “Encounter for preprocedural examinations,” based on the co-morbidities you are assessing:
• 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.”
Most pre-op exams will be coded with Z01.818. The ICD-10 instructions say to use the preprocedural diagnosis code first, and then the reason for the surgery and any additional findings.
Evaluations before surgery are reimbursable services. Select the type of service – established visit, consult, initial hospital care, etc. – and the reason for the visit in order to get paid.
– Betsy Nicoletti, a Massachusetts-based coding and billing consultant
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