July 28th, 2016
Are the following statements true or false?
• The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules.
• The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery.
• The surgeon can bill and be paid for an office visit for the purposes of a pre-op H&P after the decision for surgery is made, but before the surgery itself, if the hospital requires it.
All of these statements are false!
Let’s take them one by one:
The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules.
This is false. The primary care provider may be paid to do a medically necessary pre-operative assessment on a Medicare patient prior to surgery, but the visit is billed with a new or established patient visit code. For that matter, a cardiologist or pulmonologist can also bill for these services. The important thing: the visits must be medically necessary for the patient. Routine or screening services are not payable.
The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery.
This is false. The global surgical payment does include payment for pre-operative services, intra-operative service and post-operative care. The Medicare Fee Schedule includes the percentages for each component for each surgical CPT® code. The pre-operative care is roughly 10%, depending on the service.
When can the surgeon be paid for a pre-op visit?
• For the evaluation of the problem, if the procedure is not done that day or the next day.
• For the evaluation of the problem, if it is a minor procedure with a zero or ten day global period, when the Evaluation and Management service is a significant, separately identifiable service, meeting the criteria for using modifier 25. For example, a gynecologist is asked to see a patient with abnormal bleeding, and decides to do an endometrial biopsy on the same day. Both services may be reported and should be paid.
• For the evaluation of a problem, if it is a major procedure with a 90 day global period, and the physician decides at that visit to take the patient to surgery that day or the next day. If the visit meets the requirements for the use of modifier 57, it is a separately reportable (and payable) service.
The surgeon can bill and be paid for an office visit for the purposes of a pre-op H&P after the decision for surgery is made, but before the surgery itself, if the hospital requires it.
This is false. Some surgeons believe they can bill for a visit after the decision for surgery was made and before the surgery for the purpose of the H&P, completing the consent forms and educating the patients about what to expect. This is not a separately payable service and should not be billed.
The CPT® Assistant in May of 2009 answered this question specifically. Here is a quote from their newsletter:
If the surgeon sees a patient and makes a decision for surgery and then the patient returns for a visit where the intent of the visit is the preoperative H&P, and this service occurs in the interval between the decision-making visit and the day of surgery, regardless of when the visit occurs (1 day, 3 days, or 2 weeks), the visit is not separately billable as it is included in the surgical package.