Coding: Your Top Coding Concerns Solved
Getting clearance for pre-op services; 2008 modifier changes
By Bill Dacey Generally speaking, it’s OK to use consultation codes when a primary-care physician provides preoperative clearance services. A surgeon is asking the opinion of the primary-care provider regarding his patient’s ability to undergo a specific procedure.
Still, it’s not a perfect fit. If you use the consult codes, document correctly to support them. Many chart reviews of these pre-ops find deficiencies because there is no history of present illness (HPI).
Many practices have a pre-op form that lists the name of the surgeon, the procedure to be performed, and the date or other details related to the proposed surgery. Often the primary-care physician will write something like “severe DJD of the knee — total knee” and then move directly onto a list of medical problems, usually expressed as past medical history or a review of systems. The note then typically reviews specific risk factors. Rarely do we see the HPI-type detail we’d find in an office visit or consult.
To correct this, reference the patient’s past medical history (most often a list of chronic problems) in terms of the current status of those problems, e.g., “HTN well-controlled, pressures in the 115 range.” You need an HPI. Continued...
