The preoperative consult: A coding quiz

As family physicians, we’re accustomed to seeing patients shortly before they’re scheduled for surgery—in the office, the hospital, or other settings. But not all preoperative (preop) visits are created equal in terms of the level of care, the coding, and the documentation required. Test your knowledge:

1. A preop evaluation can be coded as a consultation visit if a request for the evaluation was initiated by:
   1. a surgeon.
   2. a patient or patient’s family member.
   3. physician self-referral.
   4. all of the above.
2. The best reason to code a preop evaluation as a consultation is:
   1. more accurate Current Procedural Terminology Evaluation and Management (CPT E/M) coding.
   2. more accurate diagnostic coding per the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) system.
   3. reimbursement is (usually) better.
   4. all of the above.
3. For outpatient consults for established patients, 2 out of the 3 key components of an encounter must be provided and documented.
   1. True.
   2. False.
4. The correct way to report the primary diagnosis for a preop consultation is to use:
   1. the ICD-9-CM code for the patient’s acute or chronic medical condition that will likely be a concern in the perioperative period (eg, diabetes mellitus, coronary artery disease).
   2. the ICD-9-CM code for the acute or chronic condition for which the patient requires surgery (eg, osteoarthritis for an elective joint replacement, or cholelithiasis for a laparoscopic cholecystectomy).
   3. V codes V72.81-V72.84 (preop exams).
   4. none of the above.
5. A comprehensive level of examination is required for:
   1. a level 4 office consultation.
   2. a level 3 inpatient consultation.
   3. a level 4 established patient office visit.
   4. none of the above.
6. Preop consultations conducted in the hospital setting should be coded using inpatient consultation codes.
   1. True.
   2. False.
   3. It depends.

QUESTION 1: When can a preop evaluation be coded as a consultation?

Answer: A When a surgeon requests the consult. Here’s why.

A consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician, or other appropriate source. In order to qualify as a consultation—CPT E/M codes 99241-99245 for outpatients and 99251-99255 for inpatients (TABLE 1)—the evaluation must be requested by any of the following:¹

• a physician
• physician assistant
• nurse practitioner
• chiropractor
• physical therapist
• occupational therapist
• speech-language pathologist
• psychologist
• social worker
• lawyer
• insurance company.

If the consultation is mandated by a third-party payer, use modifier -32 to report it.

If the preop encounter does not meet this requirement, use the customary E/M codes instead.

The physician providing the consult must clearly document the request from the surgeon or other source in the medical record.¹ Our office satisfies this requirement by using a form that is faxed to the surgeon’s office at the time the preop visit is scheduled. The surgeon completes and signs the form (sometimes with a little prodding from our office staff) and faxes it back. The signed form is affixed to the patient’s chart and available at the time of the consultation visit.

TABLE 1
Consultation codes: The right way to use them

QUESTION 2: Why should you code a preop evaluation as a consult?

Answer: D There are several reasons to code a preop evaluation performed at the request of a surgeon or other source as a consultation: Doing so offers more accurate E/M coding, more accurate diagnostic coding, and, in most cases, better reimbursement.

The preop evaluation is usually a consultation, sought by a surgeon, regarding the risks to the patient of undergoing the operative procedure and anesthesia, and strategies to provide optimal management of medical problems such as chronic obstructive pulmonary disease (COPD), diabetes mellitus, or asthma in the perioperative period. In general, consultation codes provide significantly better reimbursement than other comparable E/M codes.

For instance, the 2009 Medicare payment for a level 2 outpatient consultation (99242) in the Ohio region is $88.88. In contrast, the fee for a level 2 new patient visit (99202) is $61.71.

Include the 4 Ws: Who, why, what, and where. To bill for a consultation, however, you not only need to provide information about risks and management strategies to the clinician who requests it; you also have to clearly document that you did so. In providing the proper documentation, there are 4 aspects of the consult to consider:

1. Who requested the consult. As noted earlier, our practice requires a signed request from the surgeon for the medical record. (While a note documenting a verbal request would probably satisfy this requirement, a written request would provide much stronger evidence if an audit was done.)
2. Why the consult is being performed. Remember that a consult is initiated as a request for opinion or advice. If you are simply asked to manage a patient’s medical problems in the postoperative (postop) period, you should charge for concurrent management, not for a consultation.
3. What services you provided. Basically, this requirement simply calls for documenting your history, exam, assessment (opinion), and plan (advice). If you provide nonpreop care (such as medication refills or addressing unrelated medical issues) during the consult visit, you can bill separately for these services using modifier -25.
4. Where you sent the results of your evaluation. It is also necessary to document that you completed the loop by sending your report to the surgeon who requested the consultation. Often, I complete a handwritten consult on a history and physical (H&P) form at the request of the surgeon. I document in my note that a copy of the H&P form was faxed to the surgeon, another copy was put into the patient’s medical record in my office, and the original was given to the patient to give to the surgeon on the scheduled day of the procedure. (Electronic health records would accomplish the same thing without paper, of course.)