December 17, 2021 | By Stephanie Moore, CPC, CPMA
Many facilities will require a preoperative history and physical within 30 days of a procedure. Does this requirement from the facility support the medical necessity of an E/M visit? The answer is maybe. Medicare transmittal 1719 states, ”For purposes of billing under the Physician Fee Schedule, preoperative medical examinations performed by, or at the request of, the attending surgeon does not fall within the statutory exclusion articulated in §1862(a)(7) of the Act. These examinations are payable if they are medically necessary (i.e., based on a determination of medical necessity under §1862(a)(1)(A) of the Act) and meet the documentation requirements of the service billed”. When researching on the World Wide Web there seems to be a lot of controversy related to the billing of these services and whether they should be billed as a consult or a new vs. established patient office visit. I was surprised to see that that rose to the top and the medical necessity of these visits wasn’t the bigger concern.
Recently, I had the opportunity to work with an organization that implemented a “Pre-Op Clinic.” This clinic was created to assist with getting a backlog of patients’ medical clearance in a timely manner, within 30 days of their elective procedure, and reduce cancellations. This backlog was created by the cancellation of all elective procedures when census was over capacity and climbing due to the pandemic. As a result, during the audit review, we identified that many of the patients that were seen to be “cleared” for surgery did not meet the criteria to support medical necessity. Many of these patients were perfectly healthy individuals that were ASA class I (a normal healthy patient).
After meeting with the practice manager and the clinicians, it was very clear to me that this clinic is providing great clinical care and a wonderful service to the patients and providers. However, this does not always translate to billable services. As we dug deeper, we identified that there wasn’t a screening process or a criteria for the patients that were accepted to the clinic. Therefore, it was inevitable that there would be patients referred to the practice when it wouldn’t be appropriate to bill for all services.
A decision had to be made. Would we continue to offer this service to all patients, with the understanding that some of the patients would not be a billable service, or would we start screening patients prior to booking a pre-op clearance appointment? This would be a difficult decision and require a change in culture. During a time where burnout is a significant factor in the medical community.
If your organization is considering opening a preoperative clinic, it is important to take all things into consideration. Starting with the goal of the clinic. If it is to streamline preoperative clearance for the surgeons then the organization should be aware and realistically project the finances, knowing some of the services will not be billable. Educate your coding team so they are well versed in billing preoperative medical clearance visits. If the clinic is going to accept all referrals, health status does not matter; it is helpful for the coder to have that information. This will reassure them that the provider does not necessarily think every service is billable in an EHR that does not support a workflow for a no-charge visit. Last but not least, educating providers on the requirements for preoperative clearance from a medical necessity standpoint. The bottom line, problems need to be addressed, when reasonable and necessary, in order to meet medical necessity. To justify medical necessity the documentation should support the rationale behind addressing any problems, chronic conditions/co-morbidities to clear the patient for surgery and why. If the patient is not cleared, the rationale why the patient is not cleared and any workup that will be required in order to enable medical clearance is what will support the medical necessity of the visit.