I have a patient who came in for surgical clearance. Dr want to bill it out as a 99396 or a 99244. Do pre ops really fall under this catgory or is it just a regular E&M with a v72.84 or v72.83 dx code. Thanks for your help
Depends on insurance and the reason for the visit. It's a consult if the surgeon asked for clearance in writing or notated in the docs note and they have medical problems. If it is a 20 yr old healthy person, its a regular office visit. I would not use the 99396 ever for a pre-op
Pre-op clearance is a request from another physician to confirm the patient's current health status, for the best possible outcome for the upcoming procedure, without risks already associated with the procedure itself.
A Consultation Service should be reported, if another medical provider requests a pre-op clearance. If the examining physician knows the indication and surgery/procedure, (certainly, should), then V72.83 should be reported, followed by the reason (indication) for the procedure, then followed by co-existing conditions and current health status, (i.e., HTN, DM - stable).
A Consultation Service, even under these circumstances, requires a request from the appropriate source (not patient and/or family), identifying the physician requesting the pre-op clearance.
Preferably, the request for the Consultation Service would be written and sent via fax, Rx pad brought in by the patient, email between the physicians, snail-mail (unusual), or may be a well-documented phone call between the physicians.
Of course, a report of the patient's health status (diagnoses) is to be sent from the examining physician, back to the requesting physician.
If even just one of the components noted above are not satisfied, a Consultation Service is not supported. ** This is is problem-oriented encounter, therefore a problem-oriented E/M Service should be reported with the ICD-9 codes sequenced as noted above.