Coding for Pre-Op Exam

November 19, 2010

This practice was erroneously told to use the -56 modifier when they code surgical pre-ops

Question: 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?

Answer: 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.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@cmpmedica.com.

This question originally appeared in the July/August 2010 issue of Physicians Practice.