Report Presurgical H&P With Caution

January 29th, 2013

PhysicalHistory and physicals before surgery can be potholes in the road for reimbursement if reported incorrectly. Watch the circumstances under which the physical is performed to prevent a fiscal flat tire.

In most cases, if the surgeon performs a history and physical (H&P) to clear a patient for a scheduled surgery, you should not report a separate service. An H&P is a routine, standard procedure prior to surgery, and is separately reimbursable only if the service satisfies your payer’s medical-necessity requirements. In practical terms, a presurgical H&P is a bundled service, unless the patient presents with a new chief complaint that requires work above and beyond that normally required for such a service.

For example, a patient may develop a new problem or otherwise have had a significant change of status in the days before his surgery, which would require the surgeon to perform a more extensive evaluation. In such a circumstance, you may report the appropriate E/M service level, as supported by the key components of history, exam, and medical decision-making. Any new diagnosis or patient problems must be documented to establish medical necessity for the visit.

The rules change for services provided within 24 hours of an unscheduled and/or emergency procedure. In these cases, a surgeon making the decision for surgery during the visit would report an appropriate E/M service code with modifier 57 Decision for surgery appended.


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20 Responses to Report Presurgical H&P With Caution

  1. Lisa Benhoff CPC Says:

    Would this decision for surgery modifier -57 be appropriate to use on initial visit when our providers are requested for GI consult at the hospital, resulting in a endocopic procedere that day or subsequest days for that hospitalization? We have not been using this modifier previously.

  2. Lacy Cole Says:

    What would the rulings be for the patient’s PCP doing the pre-op clearance? Also is there a time frame prior to the surgery in which the pre-op is to be done? I have seen on the CMS website the global includes the pre op done the day prior to surgery, but what if the pre-op is done a week prior?

  3. Armen Says:

    I belive H&P is valid for 1 month, but I think you are asking if you can get paid for H&P if its done a week prior. If you submit the claim, then insurance will pay it thinking it is an E/M visit, but the article states “you should not report a separate service”, so does not matter when was it done.

  4. Lisa Fisher Says:

    The way that I understood M57 issues at Conference in Chicago, the M57 is only for major surgical procedures with 90 global period, not diagnostic or endoscopic testing procedures.

    Lisa Fisher Blackmon
    President, AAPC Mobile, AL Chapter

  5. Annie Says:

    I would like to know the rules if the PCP does the H&P also. The surgeons in our area always refer to patient to the primary care physician for the pre-op and if the patient does not have any health issues to code as diagnoses, we get denials if we just use the V-code.

  6. Emily Dingee Says:

    That is correct M57 is for use with procedures that have a 90 day global period. If the decsion is made for a minor sugery M25 is warrented.

    I agree, If your doctor see’s the patient and deciedes to do surgery in 2 weeks, you can still bill for the visit so long as it meets the requirements, you would not bill for the H&P because this would be a planned procdure.

    Emily Dingee CPC

  7. Nina Says:

    Which V-code is the PCP using for preoperative clearance? V72.83 for Other or V72.84 for Unspecified pre-operative examinations with no medically necessary diagnoses are more likely to cause your claims to deny. However, if your surgeon is trying to rule out a potential problem (aka clearing the patient) from a Cardiovascular (V72.81) or Respiratory (V72.82) standpoint; even in the absence of a clear-cut medical diagnosis of such a problem, one of those two codes may allow payment of your claims. You would also want to code any pertinent risk factors such as Family Hx of ischemic heart disease (V17.3), Personal Hx of tobacco use (V15.82), etc.

    The 25 modifier is correct for the E & M provided with decision for same day endoscopy. Most endoscopies have a “0″ (zero) day global period, so only the day of the procedure is considered included in the global period.

    Nina Leeth, CPC, CPC-I, CGIC

  8. Nancy Says:

    Lacy and Annie: It is my understanding, if the PCP does the pre-op, the PCP should bill the surgical code w/ a modifier 56 (not an E/M code) and use the surgeon’s diagnosis (reason for surgery). The sugeon should then bill w/ modifier 54 for the interoperative care, and modifier 55 for the postoperative care. The surgeon should not be billing for the global care, as he/she is not performing the pre-op portion of the global.

  9. Julie Pipke, CPC Says:

    Technically there isn’t a time period when an H&P isn’t global to a 90 day surgical procedure. I’m sure there are surgeons who feel that if it’s done a week or two prior to surgery that it’s appropriate to bill, but the surgery codes include the pre and post op work associated with the procedure, so it’s not appropriate for the surgeon to bill a pre-op H&P. The PCP can perform the pre-op consult if he/she is asked to perform it by the surgeon. You have to use the appropriate pre-op exam V code as your primary diagnosis code. If your GI provider is asked to do a consult and it results in an endoscopic procedure on the same day, you would add the 25 modifier to the consultation code. I don’t think you’ll find many PCP’s that want to take a chunk of the surgeon’s reimbursement, so it’s not a common practice to use the 56, 54, 55 modifiers. I agree that it would be correct coding though.

  10. Lena Staniscia,CPC Says:

    I work for general surgeons and my Doctors never ask the PCP to do the H&P. We bill the intial office consultation but no charge for the H&P for scheduled procedure. If We are called in as specialist consultants for a patient at the hopsital, we charge the appropriate e&M code with MOD 57 if we decide to do surgery.
    PCP are sometimes asked to clear a high risk patient.The PCP should charge an E&M with appropriate V code.

  11. Sue S. Says:

    I work in a Family Practice in Central PA. We do preop exams all the time. If it’s an H&P we code a 99214 or 99243 (depending on insurance) with the primary dx being why they are having surgery and the surgeon usually supplies this on their forms. We then use a secondary of V72.83. We only use a modifier if an EKG is done also, and the EKG dx is primary V72.81. Referring Doc is needed of course for these. And then there are usually labs required and the dx for those is primary V72.63.

  12. cpcsuzie Says:

    What about when a surgeon sends his pt to a cardiologist for cardiac clearance before a procedure? We are constantly asked to clear pts for ortho or general surgery cases in our cardiology practice and using the dx of hip injury or cholelithiasis doesn’t get us paid. What can we do with that?

  13. Dawna Says:

    Just trying to understand the difference between preop visit and initial visit. I work in a general surgery practice and can’t imagine any situation where you would want to have a surgery and not meet with the surgeon before hand. We have consults and self referrals and the visit always involves figuring out what is going on and if the patient is a candidate for surgery. Not sure if you would call this an h&p but I would assume so. Why would you not be able to bill for this?

  14. mary Says:

    I work in family practice and we do pre-ops all the time. WOuld love to know the correct way to bill these. I have asked this to many forums and never get the same answer twice.

  15. Donna Says:

    We are a PCP practice and are frequently asked to clear a patient for surgery. We use the 99243 or 99214 (depending on insurance) with the diagnosis for the surgery as well as any conditions they may have that are addressed. We also give the referring surgeons name on the claim. Who knows, tomorrow it may change :)

  16. Carol H., CPC, CCS-P, CPC-I Says:

    Every surgical procedure (major or minor) includes an element of E&M in the reimbursement. You can look at the Medicare Physician Fee Schedule Database under Type of Info: All to find the percentage of Preop, Intraop and Postop work included in the reimbursement (https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx).

    Any E&M service performed by the same physician on the same day as a minor procedure or within 24 hours of a major procedure is bundled in with the code for the procedure unless one of the following circumstances exists:

    1) The visit that determines the need for major surgery (usually those performed in the hospital with a 90 day post op period) is the one you bill with modifier -57 if the surgery is going to be performed within 24 hours. This indicates to the payer that the decision for surgery was determined at this visit.

    2) For a minor surgical procedure (typically performed in the office with 0 to 10 day post-op period), an E&M service is only billable the same day as the procedure if there is documentation of sufficient E&M elements (history, exam and medical decision making) above and beyond the surgical procedure.

    CMS says ““The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier -25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure.” (MLN: Global Surgery Fact Sheet, ICN 907166 February 2012)

    “If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.” This is the example given by CMS: “If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.”
    (Chapter 1 NCCI Policy Manual)

    If you aren’t sure whether an E&M service is warranted, ask the physician to show you in the documentation where they did something more for this patient in their E/M over and above what they normally do for that procedure. If every patient who comes in with a wart gets the same exam and a wart removal is done, the E&M is included in the wart removal. If the patient has other problems addressed that day, an E&M would be separately reportable for those issues. Do not include the wart in the decision for the level of service billed.

    For those of you providing pre-op clearance for surgery performed by another provider, it could be considered a consultation if the patient has conditions being treated by your physician and his/her opinion is requested on whether the patient is stable and cleared for surgery. If it is a standard request for a patient without any other signs, symptoms or conditions, it is part of the reimbursement for the procedure and, while splitting the surgical code(s) with modifiers -54, -55 and -56 would be correct, it is not likely that the PCP will know which code(s) the surgeon is going to bill.

    The 30-day requirement mentioned above is typically a hospital requirement, not a coding guideline. Likewise, the term H&P is a hospital term, not a coding term. An H&P is a hospital requirement, not a billable service. Physicians do not get paid for doing dictation. They get paid for date they see a patient and perform an Evaluation and Management service above and beyond other services provided.

    Hope this helps everyone!

  17. Brad Says:

    CPT states “one related E&M on the date immediately prior to OR on the date of procedure (including history and physical)” and this is if the decision for surgery has already been made.
    Every procedure includes related E&M on the day of, for minor procedures, and on the day prior as well for major procedures. It is not saying that pre operative evaluations are inherently included if performed more than a day prior to the procedure. Likewise, if a patient is seen for DJD of the knee on Monday, and is then scheduled for injection on Thursday, Mondays visit is not included in payment for the injection given on Thursday. If the injection had been given on Monday the initial evaluation MAY have been included, and Thursdays visit would probably included a brief PAR evaluation prior to the injection and would not be separately billable.

    Having said that I would personally like to see what the AMA has to say about this issue, and I would like to see it clarified in the CPT manual. You have to be careful about asking CMS for clarification on NATIONAL guidelines. Medicare is a self interested insurance company, if given the chance to not pay for something, of course it will say “yes its included”

  18. Mary Hentrup, CPC, CPC-H Says:

    Coders, You need to check the LCD for your state regarding the V codes for preops. In the state of Indiana they do not support medical necessity. Thanks

  19. Trina Says:

    My question is similar to Dawna’s above. I’m not seeing where her question was clearly answered.

    Her post stated in part, “Just trying to understand the difference between preop visit and initial visit. I work in a general surgery practice…We have consults and self referrals and the visit always involves figuring out what is going on and if the patient is a candidate for surgery….Why would you not be able to bill for this?”

    The majority of the patients at my surgeon’s office are referrals from another physician for a particular issue; for example, we see A LOT of abdominal pain patients. In most cases, the referring physician is referring for a consult to determine etiology of abdominal pain, NOT referring directly for lap chole or appy or whatever the case may be. In these cases, evaluation by our surgeon is mandatory to determining next step in the patient’s workup, whether that be endoscopy or HIDA scan or CT scan or whatever.

    If the patient is scheduled for surgery directly at this initial consult, from what I’m reading above, the initial consult is NOT billable but rather included in the global for said surgery.

    If the patient is not scheduled for surgery directly at this initial consult, again from what I’m reading above, this initial consult IS billable.

    I guess I’m confused as to when the initial consult is billable or not billable when surgery is scheduled AS A DIRECT RESULT of the initial consult. As there ANY cases when an initial consult with the surgeon would be billed as an E/M when a surgery is scheduled thereafter??

    Of course, then there are the ER consults for abdominal pain that culminate in an appy immediately thereafter. We have been billing the consults with a -57 modifier since the decision for surgery was made after the consult. The ER physician does not make the “decision for surgery,” therefore the consult with the surgeon is required.

    A second scenario is an initial consult for abdominal pain (or anemia or dysphagia, etc.), and that consult results in the scheduling of an endoscopy, something with a 0-day global period. Does this consult allow the E/M to be billed since there is technically no global period on this procedure? In very few instances, the patient is referred to us FOR an endoscopy, usually referred to us for evaluation to determine whether endoscopy is appropriate…if that makes sense.

    Can someone help? My main concern is that we have been overbilling initial consults, when they should have been part of the global.

    Thank you!

    (I am posting this in the forums, also, since the disclaimer below states this is not monitored regularly. Please disregard if it has been addressed in the forums.).

  20. Patty H. Says:

    We also have internal medicine and family practice PCP asked for formality pre op clearance all the time. The debate in our department is how to count the E/M HPI elements for a new patient in an otherwise healthy patient. Regardless if it’s codes series 99201-99205 or 99241 – 99245 what HPI elements could you possibly use when documentation is, patient is here for per-op clearance and is feeling well. A problem visit is a problem code, so what’s the problem? I understand the reason for the visit is to clear the patient for surgery, but from what condition(s)? What is the PCP’s focus on the visit going to be? If there are no problems to clear, where are your HPI elements?

    On the other hand, if this new patient has chronic conditions but is feeling well, again, what are the HPI elements for this problem visit?

    Thank you.

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