Question: As a primary-care physician, how do I code a preoperative routine physical exam?
Answer: Medicare officially stated several years ago that a physician could report a consultation code for a preoperative clearance if all the requirements of a consult are met — the consult was requested by another provider and a written report is supplied to the referring physician. The consultation code can be reported even for an encounter with an established patient. The American Academy of Family Physicians (AAFP) published an informative article on the subject once Medicare clarified its rules: www.aafp.org/fpm/20010900/16medi.html.
The AAFP (in September 2002) clarified: "Family physicians do most of these services at the request of a surgeon, who is usually seeking the family physician's opinion on whether the patient is fit for surgery. If you document this request in the patient's medical record (e.g., 'Ms. Jones seen at the request of Dr. Smith, who is requesting preoperative clearance due to X') and provide a written report to the requesting surgeon, you should be able to report these preoperative visits using a consultation code. If the service is done in the office, use an office consultation code (99241-99245); if it is provided in the hospital, use an initial inpatient consultation code (99251-99255). In either case, choose the level of service based on the level of history, exam, and medical decision-making involved, since all three key components must be met to code a given level of consultation."
As far as ICD-9 coding goes, first report the appropriate V-code for preoperative clearance (V72.81-V72.84). Next, list codes representing why the surgery is necessary, and finally, list any other conditions.