Compliance Focus
Medical Preoperative Examinations
Medicare considers routine clearance for surgery to be the responsibility of
the surgeon and included in the global fee.
If the surgeon feels that the patient has particular medical issues about which
they need additional information, they may send the patient to another physician
for an evaluation of the patient’s ability to tolerate the surgery given
the specific medical issue(s). That other physician can bill for the service and
their documentation should include the following:
1. Name of surgeon;
2. Name of procedure;
3. Need for pre-op clearance i.e. medical problems;
4. Assessment and plan; and
5. Communication to surgeon.
It is preferred that the requesting surgeon send communication to the consulting
physician; however, the consulting physician can document the request and reason
in his/her medical record. There would also be an expectation that the requesting
surgeon has documented in his/her medical record the reason for the request and
the resulting opinion.
All claims for preoperative medical examination and preoperative diagnostic
tests must be accompanied by the appropriate ICD-9 code for preoperative examination
(e.g., V72.81 through V72.84). Additionally, the appropriate ICD-9 code for the
condition(s) that prompted surgery must also be documented on the claim. Other
diagnoses and conditions affecting the patient should also be documented on the
claim, if appropriate. The ICD-9 code that appears in the line item of a preoperative
examination or diagnostic test must be the code for the appropriate preoperative
examination (e.g., V72.81 through V72.84).