How to code for travel-related counseling; coding for preoperative clearance in the hospital

Key Points

A: If you are seeing the patient for a visit and the counseling that occurs during that visit encompasses more than 50% of the time spent in the visit, then you may select the visit level based on time.

You must document the time you spent with the patient and the details of your counseling. The Current Procedural Terminology (CPT) book indicates the average time for each level of service at the bottom of the descriptors.

CODING FOR PREOPERATIVE CLEARANCE IN THE HOSPITAL

Q: Which CPT code should we use for preoperative clearance in the hospital? Can we bill for the preoperative work performed by the surgeon, or is that work included in billing for the surgery?

A: First, let me paraphrase your question to make sure I arrive at the answer for which you are looking.

From your question, I presume that a surgeon has admitted the patient to a hospital for a surgical procedure. I will refer to Medicare guidelines in my reply, but keep in mind that the response will vary by insurer if the insurer is not Medicare.

From the first part of your question, I'm not sure whether the surgeon or another provider would be rendering the preoperative clearance, so I will address both.

Codes to be used in an inpatient setting relate to initial or subsequent inpatient visits, depending on the insurer. These codes would be appropriate for use by either the surgeon or another provider evaluating the patient. If the payer is not Medicare, then it may be appropriate to bill a consultation code if the requirements are met to do so.

According to the Medicare Claims Processing Manual, for new or established patients, preoperative visits performed by any physician or nonphysician provider at the request of a surgeon are payable as long as the documentation supports the service rendered and the service is medically necessary and not routine screening.

Medical preoperative examinations and preoperative diagnostic tests performed by or at the request of the attending surgeon are payable if they are medically necessary and meet the documentation requirements to support the service.

The appropriate ICD-9-CM code for preoperative examination (for example, V72.81 through V72.84) must accompany all claims for preoperative medical examinations and preoperative diagnostic tests. Additionally, the appropriate ICD-9-CM code for the condition(s) that prompted the surgery must be documented on the claim. If the preoperative clearance is being performed for a diagnosis other than the condition prompting the surgery (an example would be a nephrologist evaluating the status of a patient's kidney function before surgery), then that diagnosis also should be included on the claim.

A physician cannot bill either an E/M or consultation for preoperative clearance if the patient doesn't have any known underlying conditions. The E/M or consultation in the absence of signs or symptoms of a disease or illness would be medically unnecessary.

The second part of the question involves billing for the preoperative work performed by the surgeon.