Primary care physicians are often asked to evaluate a patient prior to surgery at the request of the surgeon. Patients at an advanced age and those with significant medical problems face increased risk for surgical morbidity and mortality, and preoperative evaluation will depend on the extent of the patient’s condition and the type of surgery. In fact, medical billing and coding companies are well aware that evaluation and management (E&M) services before surgery can be denied reimbursement if reported incorrectly. Insurance carriers will pay only if they determine the services to be “medically necessary.”
A primary care physician’s preoperative evaluation of a patient scheduled for surgery will include:
- History – documentation of the past medical history, a review of current symptoms, a list of medications, allergies, past surgical history and family history
- Physical exam – height, weight, vital signs, and documentation of any abnormal findings on the exam of the entire body
- Assessment – a list of medical problems and a plan for each problem identified
Medicare does not consider all pre-op clearance to be medically necessary and will not routinely reimburse these services. Some pre-operative evaluation and testing services may not be covered under Medicare and that coverage and payment are determined by whether or not the service is:
- A covered benefit identified in the Social Security Act (SSA)
- Not specifically excluded from Medicare by the SSA, and
- “Reasonable and necessary” for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, or
- A covered preventive service
According to an article published by the Georgia Academy of Family Physicians in 2016, documentation when billing a preoperative medical evaluation should include the following:
- Reference to the request for a preoperative medical evaluation
- The specific medical condition that the family physician was asked to address during the preoperative evaluation (such as from a cardiovascular or respiratory point of view)
- Proof that the physician has returned his/her opinion and recommendations to the requesting provider.
For example, suppose a patient who has diabetes and hypertension comes in for preoperative examination for carpal tunnel surgery on the right wrist and the surgeon has ordered laboratory tests. The procedures involved are as follows:
- Document the requesting provider’s name and the reason for the preoperative medical evaluation.
- Forward a copy of the findings of the evaluation and management service and recommendations to the surgeon clearing the patient for surgery.
- Assign diagnosis code Z01.812 for the primary diagnosis.
- The secondary diagnosis should be the reason for the surgery: G56.01, Carpal tunnel syndrome, right upper limb.
- Code any other diagnoses and conditions affecting the patient related to the preoperative evaluation. For instance, depending on the patient’s condition, other findings to be reported may be: E11.9, controlled, type 2 diabetes and hypertension: I10, hypertension, benign.
A preoperative examination to clear the patient for surgery is part of the global surgical package, and should not be reported separately. You should report the appropriate ICD-10 code for preoperative clearance (i.e., Z01.810 – Z01.818) and the appropriate ICD-10 code for the condition that prompted surgery. All claims for preoperative evaluations should be reported using the appropriate ICD-10 code:
- Z01.810: Encounter for preprocedural cardiovascular examination
- Z01.811: Encounter for preprocedural respiratory examination
- Z01.812: Encounter for preprocedural laboratory examination
- Z01.818: Encounter for other preprocedural examination
A recent AAPC blog points out that the primary care physician can bill for the standard preoperative care if the surgeon reduces his package payment. However, Medicare does not support the regular breaking of the surgical package. Unless geographic distance or other factors prevent the patient from reasonably receiving preoperative care from the surgeon, the preventable extra costs and risks caused in processing two claims (one for the surgeon and one for the primary care physician) would be regarded as abuse by Medicare.
Putting It All Together
Let’s say an ophthalmologist requests a preoperative clearance from you for a patient who has diabetes and hypertension and is scheduled for cataract surgery, right eye. You document the requesting provider’s name and the reason for the preoperative medical evaluation. Then you perform an evaluation and management service and forward a copy of your findings and recommendations to the ophthalmologist clearing the patient for surgery.
When you bill for this service, the primary diagnosis on the claim and the one attached to the EM code on the line item will be a Z code (e.g., Z01.818, “Encounter for other preprocedural examination”). The secondary diagnosis will be the reason for the surgery, the cataract in the right eye (e.g., H25.031, “Anterior subcapsular polar age-related cataract, right eye”). Finally, if appropriate, you would also code the patient’s diabetes (e.g., E11.9, controlled, type 2 diabetes) and hypertension (e.g., I10, hypertension, benign).
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Modifier 25 is used when a minor procedure (one with a 0- or 10-day global period) and a significant and separately identifiable evaluation and management (E/M) service are performed during the same session or day. Modifier 25 (significant, separately identifiable evaluation and management [E/M] service by the same 
