Documenting Correctly for a Preoperative Medical
Evaluation
Prepared
by Steve Adams, MCS, COC, CPC, CPMA, CPC-I, PCS, FCS, COA
InHealth
Professional Services
The Issue
This article will outline the
three things we need to see in your documentation when billing a preoperative
medical evaluation:
- Reference to the request for a preoperative medical evaluation
- The specific medical condition you were asked to address during the preoperative evaluation (e.g. from a cardiovascular or respiratory standpoint); and
- Proof that you have returned your opinion and advice to the requesting provider.
The Past
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).
