| |
February 2002
Volume 66 |
Number 2
|
| |
PRACTICE
MANAGEMENT
|
| Preoperative
Visits – Should I Bill for Them? |
Karin Bierstein, J.D.
Assistant Director of Governmental Affairs (Regulatory)
The question of whether anesthesiologists may bill separately
for preoperative evaluations has resurfaced recently. The answer
is not entirely black or white, although it is clear that the
routine preanesthesia evaluation performed on every surgical patient
is not billable. The ASA Relative Value Guide explicitly states
that the “usual preoperative and postoperative visits”
are included in the base units for an anesthesia service.
There are circumstances, however, under which a preoperative
evaluation performed by an anesthesiologist may properly be billed,
at least to Medicare. A visit or consultation that goes significantly
above and beyond the routine preanesthesia visit will qualify,
in general. The Centers for Medicare & Medicaid Services (CMS)
spelled out the applicable circumstances in a new section of the
Medicare Carrier Manual (MCM), of which carriers were advised
in May 2001. Section 15047 of the MCM provides that: “E/M
[Evaluation and Management] services performed … for the
purpose of evaluating a patient’s risk of perioperative complications
and to optimize perioperative care … may be billed by using
an appropriate CPT [Current Procedural Terminology™] code
(e.g., new patient, established patient, or consultation).”
This distinguishes preoperative evaluations from routine screening
examinations, which Medicare does not cover. There are important
qualifications, however.
Medical Necessity. Section 15047 provides that: “For
purposes of billing under the Physician Fee Schedule, medical
preoperative examinations performed by, or at the request of,
the attending surgeon … are payable if they are medically
necessary (i.e., based on a determination of medical necessity…),
and meet the documentation requirements of the service billed.”
Determination of the appropriate E/M code is based on the requirements
of the specific type and level of visit or consultation the physician
submits on his or her claim (e.g., established patient, new patient,
consultation).
To be medically necessary for payment purposes, a preoperative
evaluation would have to encompass more than the standard preanesthesia
exam. At one end of the spectrum, the full history and physical
exam required by the hospital — if provided by the anesthesiologist
— would certainly qualify. A good example would be the history
and physical for a procedure to be performed by a nonphysician
provider, e.g., a podiatrist, who is not licensed to conduct a
medical evaluation. A visit separate from the preanesthesia evaluation
also could be medically necessary if the patient had known medical
conditions that might cause perioperative problems.
To distinguish between preoperative exams and the routine preanesthesia
visit, readers should consult the “Practice Advisory for
Preanesthesia Evaluation” approved by the ASA House of Delegates
in October 2001 <www.asahq.org/Pubs/pubshome.htm#practice>.
The purposes of the practice advisory do not include resolving
payment issues, but its “reference framework for the conduct
of preanesthesia evaluation by anesthesiologists” is highly
relevant. The content of the preanesthesia evaluation “includes
but is not limited to 1) readily accessible medical records, 2)
patient interview, 3) a directed preanesthesia examination, 4)
preoperative tests when indicated and 5) other consultations when
appropriate. At a minimum, a directed preanesthetic physical
examination should include an assessment of the airway, lungs
and heart.”
Finally, the chair of our Committee on Economics, Alexander A.
Hannenberg, M.D., observes that “anesthesiologists choosing
to report [preoperative] patient evaluations separately will rely
on the individual merits of each case in any dispute with a carrier
on the appropriateness of billing these visits. Local carriers
may be willing to develop guidelines in this area, and the anesthesiologist
member of the local Carrier Advisory Committee may be able to
facilitate such efforts.”
Documentation. To demonstrate that the Medicare conditions
for payment of the preoperative visit have been satisfied, documentation
of the following is critical (the only requirements for commercial
payers would be those contained in contracts or in the CPT-4 guidelines):
- Request for a visit or consult by the attending surgeon. You
should only bill Medicare for a consultation if, additionally,
you prepare a report of your findings “which is provided
to the referring physician [i.e., the surgeon] for the referring
physician’s use in treatment of the patient.” (MCM
Section 15506).
- Medical necessity, e.g., ICD-9 codes for the conditions that
prompted surgery and for the condition that prompted the preoperative
medical evaluation, if any.
- The appropriate preoperative service ICD-9 codes, e.g., V72.81
through V72.84.
- Level of E/M code selected.
- Timing. A claim for a preoperative visit provided on the same
day as the anesthetic is more likely to raise a Medicare carrier’s
suspicion than a claim for an examination performed in advance.
Preoperative Tests
Anesthesiologists do not perform preoperative tests such as electrocardiograms
and are therefore not paid for such tests. The hospital, on the
other hand, may well lose money on tests that are deemed medically
unnecessary and hence not reimbursed. It is therefore important
for anesthesiologists to understand the application of the medical
necessity concept to preoperative tests.
The Medicare Carrier Manual does not elaborate on the medical
necessity of preoperative diagnostic tests, but ASA’s “Practice
Advisory for Preanesthesia Evaluation” states the following:
“The Task Force agrees with the consultants and ASA members
that preoperative tests should not be ordered routinely. The Task
Force agrees that preoperative tests may be ordered, required
or performed on a selective basis for purposes of guiding or optimizing
perioperative management. The indications for such testing should
be documented and based on information obtained from medical records,
patient interview, physical examination and type and invasiveness
of the planned procedure.”
The advisory devotes several pages to specific preoperative tests
such as electrocardiograms and chest X-rays, listing specific
medical conditions that may warrant individual tests. It is a
very useful guide.
Correction - Table 2, Page 33 of December
2001 NEWSLETTER (Medicare Base Unit Update)
return to top
|