Pre-operative medical exams

Medically necessary pre-operative evaluations are covered services by Medicare and other third party payers.  Typically, the surgeon who will perform the surgery asks the patient's primary care physician or sub-specialist to clear the patient prior to a major surgery.  This service must be medically necessary and not routine.  It is not meant to remove the pre-operative work from the surgeon.  

Here is what CMS says:

"Pre-operative consultations are payable for new or established patients performed by any physician or qualified NPP at the request of the surgeon as long as all the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not a routine screening."  

Starting January 1, 2010, use new or established visit codes for per-operative visits for Medicare patients, because consultations are no longer payable. Remember that the service has to be medically necessary.  If a service is being performed simply to meet the requirements of the surgery center or the hospital then it should not be considered a medically necessary visit.  Medically necessary means that there is a medical reason for this particular patient.

Commercial insurances

Physicians may still use consults for pre-operative evaluations for patients with commercial insurances. Physicians often bill for these medically necessary pre-operative clearances using consult codes but neglect to document them as consults.  If the first sentence is “I am seeing her for a pre-op exam prior to her scheduled surgery," that is an office visit.  If the first sentence is, "I am seeing Ms. Jones at the request of Dr. Orthopedics for my medical evaluation of her problems prior to her knee surgery,” and there's evidence that a copy of the report is returned, then bill a consultation.  

Consultations require a higher level of documentation than established patient visits and pay at a higher level.  Remember to document the history of the present illness elements.  It is insufficient to say the patient is having a knee surgery.  Document either the problems they were having with their knee, particularly if that is related to a medical specialty, or document their chronic medical conditions that required a pre-op evaluation.  

For example, “I am seeing this patient at the request of Dr. Ortho in order to review her hypertension, diabetes and atrial fibrillation prior to her knee surgery.”  

Keep in mind that a consult requires evidence that a report was returned to the requesting physician.

The ICD-9 book tells us to bill using the V72.8X codes for these visits.  (These codes indicate a pre-op exam.)  However, some carriers consider services billed with these diagnoses codes to be routine and not medically necessary.  Some payers recommend using the patient’s medical condition in the first position on the claim form, and the V72.8X codes in the second position.   

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