Coding for pre-op exam
Q We are a primary care and endocrinology/diabetes group who is asked by various surgical offices to do preoperation exams and surgical clearances for our patients. The pre-op usually includes EKG with interpretation, lab work, and plan of care assessment pre- and post-op. After attending a recent coding seminar we realized we were not coding these correctly and should be asking, at the time of making the appointment with the surgical office, for the surgical code(s) and adding a -56 modifier on our billings, then as a courtesy reminding the surgical office to also add a modifier to their billing. Most offices seem aware of this and are happy to comply, and we have indeed received our portion of the fee from various insurance companies. We have run into some resistance with one group in particular, which leads us to some doubt and need for verification from an expert coder. Are we in fact coding/billing surgical clearances correctly now, or do we go back to billing E&M codes?
A I don’t know where you got this guidance, but I don’t think it’s the best. There is no single source of direct authoritative guidance I know of that says don’t do this, but there’s plenty of anecdotal direction.
The pre-op component of a surgical procedure is intended to be the preoperative services normally associated with that procedure, and performed by the provider performing the surgery. That is why it is part of the global package — it is part of those pre-op services normally included in the package. Most Medicare carriers also do not recognize modifier -56, if that says anything.
The services provided by a primary-care provider to clear a patient for
surgery are services to assess the other problems the patient may have, any
problems or conditions that may impact risk or contraindicate surgery, or those
that simply need to be cleared. It is a separate assessment, or potentially
different problems not related to the reason for the surgery, performed by a
separate provider. It has long been recognized as best represented by a consult
code in terms of code type.
On a side note I did find in a Medicare based coding software that -56 is listed so I did find this interesting.
-56 Preoperative Management Only: When 1 physician performed the
preoperative care and evaluation and another physician
performed the surgical procedure, the preoperative component
may be identified by adding modifier 56 to the usual procedure
Anyone have any thoughts or experiences in this situation? So do you use to the surgical dx and CPT code as it is a different physician or do you use a different dx and the E&M codes? Just a topic for discussion.