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How to properly code for a pre-op examination

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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Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use .

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preoperative visit cpt code

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.

preoperative visit cpt code

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

preoperative visit cpt code

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:

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How should you code pre-op exams and who can perform them.

On the surface, coding preoperative visits is relatively straightforward: 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, and 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 , an organization representing professional coders, billers, auditors, compliance professionals, documentation specialists and practice managers. “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 five best practices to help coders report preoperative visits correctly 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 he or she can withstand surgery. Healthy patients don’t generally require a preoperative visit, and providing one may not be medically necessary. 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 frequently perform preoperative clearance because they’re the ones typically managing the conditions that could affect surgery.

Surgeons may try to bill these visits without realizing that any preoperative evaluations they perform after the decision to perform surgery is made are included in 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 surgery is made. For example, a patient decides to have surgery but then delays surgery 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, ‘Ok, 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 Three Different ICD-10-CM Diagnosis Codes

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

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

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 he or she 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 three diagnosis codes (in this order):

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

The sequence of the codes 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, they should 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) as well as the ICD-10-CM diagnosis codes that denote the COPD and arrhythmia. This is in addition to the reason for surgery (reported last in the sequence).

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) why the patient isn’t cleared for surgery and any course of action that’s necessary to enable clearance (e.g., prescribe a course of antibiotics to treat congestion)

5. Distinguish Between ‘Clearance’ and ‘Decision for Surgery’

Unlike visits for preoperative clearance, 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. 

To talk to a  Kareo Solutions Consultant about improving documentation for reliable reimbursement:

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January 31, 2024

Pre-operative clearance in primary care

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Last revised December 18, 2023 - Betsy Nicoletti Tags: primary care_E/M services

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions.

preoperative visit cpt code

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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Pre-Op Physicals

Here is guidance on how your medical practice should code a preoperative routine physical exam, including when to use CPT codes 99241-99245 and 99251-99255.

Question: As a primary-care physician, how do I code a preoperative routine physical exam?

Answer: Medicare officially stated several years ago that a physician could report a consultation code for a preoperative clearance if all the requirements of a consult are met - the consult was requested by another provider and a written report is supplied to the referring physician. The consultation code can be reported even for an encounter with an established patient. The American Academy of Family Physicians (AAFP) published an informative article on the subject once Medicare clarified its rules: www.aafp.org/fpm/20010900/16medi.html . The AAFP (in September 2002) clarified: "Family physicians do most of these services at the request of a surgeon, who is usually seeking the family physician's opinion on whether the patient is fit for surgery. If you document this request in the patient's medical record (e.g., 'Ms. Jones seen at the request of Dr. Smith, who is requesting preoperative clearance due to X') and provide a written report to the requesting surgeon, you should be able to report these preoperative visits using a consultation code. If the service is done in the office, use an office consultation code (99241-99245); if it is provided in the hospital, use an initial inpatient consultation code (99251-99255). In either case, choose the level of service based on the level of history, exam, and medical decision-making involved, since all three key components must be met to code a given level of consultation." As far as ICD-9 coding goes, first report the appropriate V-code for preoperative clearance (V72.81-V72.84). Next, list codes representing why the surgery is necessary, and finally, list any other conditions.

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preoperative visit cpt code

Medical Billing and Coding - Procedure code, ICD CODE.

Pre-operative Consultation CPT 99241, 99275 – v72.81 , 336.13

Mar 13, 2011 | Medical billing basics

Pre-operative Consultation

The appropriate consultation code (99241-99275) may be reported for a preoperative consultation performed by any provider, to include a patient’s primary care provider, at the request of a surgeon, as long as all the consultation requirements are met and the service is medically necessary. 

In reporting the diagnosis, it is important to remember that the role of each code is to explain why a service was provided.  In reporting “preoperative clearance” the first diagnosis code used would be the code for preoperative examination (e.g., V72.81 throughV72.84).  Additional ICD-9 codes for the condition(s) that prompted surgery and for conditions that prompted the preoperative medical evaluation should also be documented and reported.  This underlying condition determines the medical necessity for the “preoperative clearance.”  Other diagnoses and conditions affecting the patient may also be documented and reported if appropriate.

Example: V72.81        Pre-operative cardiovascular examination 336.13        Anterior subcapsular polar senile cataract – Reason for the patient’s surgery 401.1        Essential hypertension benign – Underlying condition – why medical clearance was needed.

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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.

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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

Medical Billers and Coders – If You Have Billing Challenges

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, 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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Coding for a primary care preoperative exam

Can I bill for a preoperative visit, and if so, what CPT code should be used?

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

preoperative visit cpt code

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preoperative visit cpt code

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COMMENTS

  1. How to properly code for a pre-op 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....

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

    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.

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

    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.

  4. How Should You Code Pre-Op Exams and Who Can Perform Them?

    Z01.811 (Encounter for preprocedural respiratory examination) J44.1 (COPD with acute exacerbation) M17.11 (Unilateral primary osteoarthritis of the right knee) The sequence of the codes is important because the Z code indicates to payers that the purpose of the visit is for preoperative clearance, says Jimenez.

  5. How to Code a Preoperative Clearance

    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.

  6. Your Quick Guide to the Global Surgical Package

    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

  7. Pre-operative clearance in primary care

    Primary care practices are frequently asked to do pre-operative evaluations or clearances on their own patients by a surgeon. ... pre-op clearance, pre-op visits by primary care. Last revised December ... other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged ...

  8. Patient Pre-optimization Quick Coding Guide

    CPT Code: 99212-99215 Description: Office or other outpatient visit for the evaluation and management of an established patient. Medical decision making and time criteria varies by code. Notes:

  9. PDF Patient Pre-optimization

    CPT Code 99424 +99425 99426 Description Principal care management services, for a single high-risk disease, with the following required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/ decompensation, functional decline, or death,

  10. Are You Coding Pre-Operative Clearances Correctly?

    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.

  11. Pre operative visits

    What is the correct way to code pre operative visits? I've read so much about it that I'm getting confused, especially regarding decision for surgery visits and preoperative clearance visits. Thanks! A AlaskanCoder Guru Messages 151 Location Anchorage, Alaska Best answers 0 Aug 16, 2016 #2

  12. Pre-Op Physicals

    Application error: a client-side exception has occurred (see the browser console for more information). Here is guidance on how your medical practice should code a preoperative routine physical exam, including when to use CPT codes 99241-99245 and 99251-99255.

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

    cpt code/modifier surgeon/physician; may 8: 66982-54: surgeon: may 9: 66982-55: ... surgical care only: when one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier -54 to the usual procedure number or by use of the separate five ...

  14. Pre-operative Consultation CPT 99241, 99275

    The appropriate consultation code (99241-99275) may be reported for a preoperative consultation performed by any provider, to include a patient's primary care provider, at the request of a surgeon, as long as all the consultation requirements are met and the service is medically necessary.

  15. PDF New Physicians and Residents: Billing and Coding Danielle Cooley, DO

    Preoperative Visits- Diagnosis Codes 1. Pre-operative Risk Z01.810- Cardiac Pre-op exam Z01.811- Respiratory Pre-op Exam Z01.818- General Pre-Op Exam 2. Diagnosis that is requiring the patient to have surgery 3. Diagnosis that is putting the patient at risk Preoperative Visit- Example 1. Z01.810- Cardiac Exam 2. K80.20 Gallstones 3. I50.42 ...

  16. PDF MLN907166

    When billing co-surgeons' claims using modifier -62, the fee schedule amount for each co-surgeon is 62.5% of the global surgery fee schedule amount. We pay the team surgery (modifier -66) on a report basis. Get more guidance in Section 40.8 of the Medicare Claims Processing Manual, Chapter 12.

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

    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 ...

  18. Coding for Preoperative Visits : Reader Questions

    Coding for Preoperative Visits. Published on Sun Dec 01, 2002. Question: In the July 2002 issue, you state that the pre-op visit is included in the surgery global package and that billing separately for it is fraudulent. In the January 2002 issue, however, the cover article states that the "CPT guidelines indicate that the E/M visit that occurs ...

  19. Correct Coding for Pre-operative Clearance

    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

  20. Wiki Pre-Op visits prior to the day before

    1formissy Oct 9, 2023 Create Wiki 1formissy Guru Messages 237 Location Albany, OR Best answers 0 Oct 9, 2023 #1 In the case that a physician sees a patient a week before the planned major surgery with no changes to the plan, but the physician indicates and documents it is medically necessary, would that E/M be reportable?

  21. Coding for a primary care preoperative exam

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