This is my July Coding Newsletter - Hope you like

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:

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.

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).