Correct Coding for Pre-operative Clearance

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Correct Coding for Pre-operative Clearance

• Pre-operative evaluation and testing services may
  not be covered under Medicare. Primary care
  physicians are often asked to evaluate a patient
  prior to surgery at the request of the surgeon.
  Patients at an advanced age and those with
  significant medical problems face increased risk
  for surgical morbidity and mortality, and
  preoperative evaluation will depend on the extent
  of the patients condition and the type of
  surgery.
• In fact, medical billing and coding companies are
  well aware that evaluation and management (EM)
  services before surgery can be denied
  reimbursement if reported incorrectly. Insurance
  carriers will pay only if they determine the
  services to be medically necessary.
• A primary care physicians preoperative
  evaluation of a patient scheduled for surgery
  will include
• History  documentation of the past medical
  history, a review of current symptoms, a list of
  medications, allergies, past surgical history,
  and family history
• Physical exam  height, weight, vital signs, and
  documentation of any abnormal findings on the
  exam of the entire body
• Assessment  a list of medical problems and a
  plan for each problem identified

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Correct Coding for Pre-operative Clearance

• Pre-operative clearance
•  
• Medicare does not consider all pre-operative
  clearance to be medically necessary and will not
  routinely reimburse these services. Some
  pre-operative evaluation and testing services may
  not be covered under Medicare and that coverage
  and payment are determined by whether or not the
  service is
• A covered benefit identified in the Social
  Security Act (SSA)
• Not specifically excluded from Medicare by the
  SSA, and
• Reasonable and necessary for the diagnosis or
  treatment of an illness or injury or to improve
  the functioning of a malformed body member, or
• A covered preventive service

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Correct Coding for Pre-operative Clearance

• Pre-operative medical evaluation
• According to an article published by the Georgia
  Academy of Family Physicians in 2016,
  documentation when billing a preoperative medical
  evaluation should include the following
• Reference to the request for a preoperative
  medical evaluation
• The specific medical condition that the family
  physician was asked to address during the
  preoperative evaluation (such as from a
  cardiovascular or respiratory point of view)
• Proof that the physician has returned his/her
  opinion and recommendations to the requesting
  provider.
• For example, suppose a patient who has diabetes
  and hypertension comes in for preoperative
  examination for carpal tunnel surgery on the
  right wrist and the surgeon has ordered
  laboratory tests. The procedures involved are as
  follows
• Document the requesting providers name and the
  reason for the preoperative medical evaluation.
• Forward a copy of the findings of the evaluation
  and management service and recommendations to the
  surgeon clearing the patient for surgery.

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Correct Coding for Pre-operative Clearance

• Assign diagnosis code Z01.812 for the primary
  diagnosis.
• The secondary diagnosis should be the reason for
  the surgery G56.01, Carpal tunnel syndrome,
  right upper limb.
• Code any other diagnoses and conditions affecting
  the patient related to the preoperative
  evaluation. For instance, depending on the
  patients condition, other findings to be
  reported may be E11.9, controlled, type 2
  diabetes, and hypertension I10, hypertension,
  benign.
• A preoperative examination to clear the patient
  for surgery is part of the global surgical
  package, and should not be reported separately.
  You should report the appropriate ICD-10 code for
  preoperative clearance (i.e., Z01.810 Z01.818)
  and the appropriate ICD-10 code for the condition
  that prompted surgery. All claims for
  preoperative evaluations should be reported using
  the appropriate ICD-10 code
• Z01.810 Encounter for preprocedural
  cardiovascular examination
• Z01.811 Encounter for preprocedural respiratory
  examination
• Z01.812 Encounter for preprocedural laboratory
  examination
• Z01.818 Encounter for other preprocedural
  examination

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Correct Coding for Pre-operative Clearance
A recent AAPC blog points out that the primary
care physician can bill for the standard
preoperative care if the surgeon reduces his
package payment. However, Medicare does not
support the regular breaking of the surgical
package. Unless geographic distance or other
factors prevent the patient from reasonably
receiving preoperative care from the surgeon, the
preventable extra costs and risks caused in
processing two claims (one for the surgeon and
one for the primary care physician) would be
regarded as abuse by Medicare. Putting It All
Together Lets say an ophthalmologist requests a
preoperative clearance from you for a patient who
has diabetes and hypertension and is scheduled
for cataract surgery in, the right eye. You
document the requesting providers 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.
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Correct Coding for Pre-operative Clearance
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 patients diabetes (e.g., E11.9,
controlled, type 2 diabetes) and hypertension
(e.g., I10, hypertension, benign). Stuck at
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Correct Coding for Pre-operative Clearance

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Correct Coding for Pre-operative Clearance

• FAQs
• 1. How do you code a pre-operative clearance?
• To code a pre-operative clearance, use relevant
  ICD-10 codes reflecting the patients condition
  and reason for surgery.
• 2. What is the ICD-10 code for pre-operative
  clearance?
• The ICD-10 code for pre-operative clearance falls
  under Z01.810 to Z01.818, depending on the type
  of examination.
• 3. What is the purpose of the Pre-operative
  assessment?
• Pre-operative assessments aim to evaluate a
  patients health before surgery to optimize care
  and minimize risks.
• 4. What happens during a medical clearance?

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Correct Coding for Pre-operative Clearance
During medical clearance, providers review
medical history, conduct exams, and order tests
to ensure the patient is fit for surgery. 5.
Does Medicare pay for preoperative
clearance? Medicares coverage for preoperative
clearance varies based on service necessity and
coverage policies. Check eligibility before
proceeding.