Pre-op visits: True or False?

December 29th, 2015 - Codapedia Editor
Categories:   Coding   Compliance   Evaluation & Management (E/M)   Modifiers   Surgical Billing & Coding  
0 Votes - Sign in to vote or comment.

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:  

 If the surgeon sees a 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.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Impact of 2021 Proposed Medicare Fee Schedule on Chiropractic Offices
August 7th, 2020 - Wyn Staheli, Director of Research
On August 3, 2020, the proposed Medicare Physician Fee Schedule for 2021 was released. This 1,355 page document includes some sweeping changes to the Medicare program. There are a few items in particular which should be noted by chiropractic offices.
Coding with PCS When There is No Code
August 5th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
ICD-10-PCS covers ALMOST everything! But not quite! What if a body system does not contain a body part for toes or fingers? What about an elbow? When it does not cover what you are looking for, where do you turn?  To the guidelines, of course! There are ICD-10-PCS guidelines just as ...
To Our Codapedia Friends!
July 30th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Codapedia friends, come and join us at Find-A-Code - a core product of innoviHealth! The information found on Codapedia comes from our sister company, Find-A-Code. If you do not already have a subscription with the greatest online coding encyclopedia, call us and get signed up today. We are offering a ...
OIG Report Highlights Need to Understand Guidelines
July 28th, 2020 - Wyn Staheli, Director of Research
A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.
Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately
July 21st, 2020 - Aimee Wilcox
We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...
Use the Correct Diagnosis Codes and Revenue Codes to Get Paid for PAD Rehab
July 15th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
The initial treatment in rehabilitation for patients suffering from Intermittent Claudication (IC) is Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  Rehabilitation using SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest.   When reporting 93668 for peripheral arterial disease rehabilitation the following ...
New Name Same Great Product! "HCC Plus"
July 14th, 2020 - Find-A-Code
Hello HCC Customers! We have made a change in name only to our HCC subscription. The new subscription is now called “HCC Plus”. Keep in mind there have been no changes to the product. Using your subscription along with the risk adjustment calculator will ensure you stay current with...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association