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Find-A-Code Articles, Published 2023, September 12

Documenting and reporting postoperative visits.

by   Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT Sep 12th, 2023

CPT® 99024 was introduced by the American Medical Association (AMA) with an effective reporting date of January 1, 2013. The associated code description is as follows:,&nbsp

“Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure”

To fully understand this code description, one must also understand the definition of the global surgical package, which CPT® describes as: 

Of note, Medicare published their own definition of the global surgical package (see Chapter 12, Section 40.1 of the Medicare Claims Processing Manual-Pub. 100–04), which differs from the CPT® surgical package. The surgical package policy applied to an individual claim is determined by the patient’s insurance company’s published policies.Payers without published policies must adhere to the CPT® guidelines.

Prior to 2017, pre/postoperative services with a zero-dollar charge, were not submitted on claims. Because of this, a proper analysis of the quality and quantity of services that make up a global surgical package was not possible, as there was a deficit in the data that showed postoperative services. In 2015, Medicare proposed a change in the global surgical package to return all surgical procedures to a zero-day global period to promote a more accurate valuation of surgical services through coding data. However, Section 523(a) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114–10, enacted April 16, 2015) added section 1848(c)(8)(A) of the Act, prohibited the Secretary from implementing this change. 

Instead, on January 1, 2017, Medicare required specific large provider groups, identified by them, to report via claim, all preoperative and postoperative services provided during the global surgical period. Although the requirement was only specific to certain large provider groups and not all Medicare providers, all Medicare contracted providers were encouraged to do likewise. This policy was strategic to facilitate a more accurate valuation of more than 4,000 surgical procedures assigned a 0, 10, or 90-day global period.

Each surgical procedure is assigned either a 0, 10, or 90-day global period; however, according to the global surgical package, the day of the procedure is considered bundled into the procedure for 0-day and 10-day global periods, which means technically the 10-day global period is actually an 11-day global period (day of the procedure and the 10 days following the procedure). For 90-day global periods, which are considered to be major surgical procedures, the day prior to the surgery, the day of the surgery, and 90 days following the surgery, are included in the global period, essentially making a 90-day global period actually a 92-day global period. 

Preoperative services performed on the day of a 0-day or 10-day surgical procedure are bundled into the procedure itself. As an example, let’s review the following patient scenario: 

Scenario: A patient has an appointment to have their nails trimmed in the office. The physician documents a history related to the patient’s chronic conditions and how they impact his ability to trim his own nails, examines the patient’s nails, and determines there are 8 that need to be trimmed. The provider documents the procedure where the nails are trimmed, including the method used, the nails trimmed, and the outcome and any instructions on nail care to the patient. 

Code: 11721 - Debridement of nail(s) by any method(s); 6 or more is reported but not anEvaluation and Management (E/M) service code. The reason being, is that this was a scheduled procedure and all of the history and exam were related to why the patient has the condition, needs the service performed, and the actual performance of the service, all of which are considered the preoperative workup included (bundled) into the service itself. 

Same Day Surgeries

Currently, there are 1,190 surgical procedures with a zero-day global period, 468 surgical procedures with a 10-day global period, and 3,743 major surgical procedures with a 90-day global period. Code 99024 is used to report postoperative services, beginning with any postoperative care provided on the day of the surgery (after the surgery has been performed) and each visit thereafter, where postoperative care is provided through the end of the assigned global period.  For same day surgeries (SDS), that means all care related to admitting the patient, postoperative care up until discharge, and inclusive of the discharge services. The same applies to admission and discharge services, as well as inpatient E/M services provided to a patient in the inpatient hospital setting. Facilities who accurately report all postoperative services with 99024 during the global period would also report 99024 for any admission and discharge services, instead of the usual CPT codes for those services, and all are bundled into the surgical package, unless specific surgical or patient care for other conditions or complications is provided that is beyond what is covered in the surgical package. 

However, it should be noted that if the surgeon is billing for Evaluation and Management services, during the global period, that are unrelated to the surgical procedure and global period, and the documentation supports the clear distinction of these services, the provider may report the E/M service with modifier 24 to specify it is a distinct and separately billable service provided during the global period. 

Splitting Surgery and Postoperative Care

Occasionally, the surgeon who performs the surgery is not available to perform the preoperative and postoperative care. This can be because pre and postoperative services are provided in a different state than the surgeon resides and the patient has returned home after surgery to get postoperative care by their own physician, or another reason exists. Be sure to check individual payer policies related to splitting the surgical global package components to ensure coverage, medical necessity, documentation requirements, and modifier use for reporting claims. 

When the global surgical package is split between providers for Medicare beneficiaries, each provider will report the surgical CPT code and the modifier that applies to the services they are providing and in the narrative box on the claim, will provide the details of the services and service dates they are providing to the patient. Novitas, and other Medicare Administrative Contractors (MACs) have provided published documents to review this process in detail.

Documentation

Clear documentation is very important in ensuring accurate reimbursement for services rendered, whether for the entire global surgical package or when it has to be split between providers. An operative report that clearly describes the pre/postoperative diagnosis, name of the procedure, and the details of how it was performed, is a must have for claims submission and medical necessity. Likewise, each postoperative report should contain language that indicates the patient is presenting for a postoperative visit, including the postoperative date (e.g., POD#7, status post day 7) and the surgical procedure they had done, including the date the procedure was performed. This facilitates proper coding for the global period and an accurate reflection of postoperative care provided to the patient following surgery. 

Additionally, be sure to document any postoperative care, such as: 

• Patient complaints, symptoms, or complications directly related to the surgical procedure.
• Examination of the patient, especially the body area or organ system impacted by surgery.
• Medications or treatments that have been prescribed, including pain management. 
• Follow-up testing or imaging ordered to check the patient’s status after surgery.
• Any conditions, symptoms, or treatments that are unrelated to the surgical procedure that may qualify for appending modifier 25 to the E/M service.

Separately Reportable E/M Service on the Day of a Postoperative Visit by the Same Provider

When a postoperative visit turns into an E/M service for an unrelated condition, the provider may be eligible for payment if the documentation supports a separately, identifiable E/M service as well as the postoperative visit service. Providers often combine these two services in a single report; however, to ensure accurate payment and reduce confusion that may occur during an audit, we recommend either documenting the postoperative care first and in the same note, just separated from it, document a complete E/M service note as well for the unrelated problem. Providers may also choose to simply document two separate reports, one for the postoperative visit and another for the separately identifiable E/M service on the same date. To ensure the E/M service is paid, when the documentation qualifies the service, report modifier 24 (unrelated E/M by the same physician during the postoperative period) with the E/M service code to clarify it is an unrelated service. If supporting documentation is requested by the payer, be sure to send both reports, the postoperative note and the E/M service note for clarity. 

Of note, there is no NCCI edit between 99024 and E/M service codes indicating that if both a postoperative visit and an unrelated E/M service are performed on the same day by the same physician/provider, they may be reported on the same claim; however, be sure to append modifier 24 to the E/M service code to instruct the payer that the provider documentation supports unbundling the E/M service from the global period for payment.

References/Resources

About aimee l. wilcox, cpma, ccs-p, cst, ma, mt.

Documenting and Reporting Postoperative Visits. (2023, September 12). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/documenting-reporting-postoperative-visits-37422.html

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October 25, 2023

Getting Paid

Medical Billing & Coding

Pre-op CPT codes: How to properly code preoperative exams

Mastering pre-op coding is crucial. Here are 5 key practices, from patient clearance to ICD-10-CM codes, to ensure accurate billing and avoid denials.

Most Popular

At a glance.

• Not all patients need pre-op clearance; healthy ones usually don’t.
• Specialists often perform clearance, but surgeons must avoid billing separately.
• Report 3 ICD-10-CM codes for pre-op clearance, specifying exam purpose.

On the surface, coding preoperative visits is relatively straightforward. Simply choose the evaluation and management (E/M) code that most accurately represents the medical decision-making and patient acuity.

However, there’s more to it than that. Coders need to understand the nuances of reporting these visits if they want to avoid payer scrutiny , says Raemarie Jimenez, vice president, member and certification development, at AAPC . “It’s one thing to go through the steps for good clinical care,” she says. “It’s another thing as to when it’s a billable service.”

Jimenez provides the following 5 best practices to help coders report preoperative visits correctly using pre op CPT (Current Procedural Terminology ) codes and avoid costly denials .

1. Recognize that not every patient requires pre-op clearance 

The purpose of a preoperative visit is to evaluate a patient’s complicating health condition to determine whether they can withstand surgery. Healthy patients don’t generally require a preoperative visit. Surgeons may evaluate healthy patients to determine whether surgery is necessary. However, they don’t typically need to send these patients to a primary care physician, internist, or specialist to clear them for the surgery.

2. Know who can perform pre-op clearance

Specialists and internal medicine physicians are among those who most often perform preoperative clearance because they’re the ones typically managing the conditions that could affect surgery. They are relevant for pre op CPT codes.

“ It’s one thing to go through the steps for good clinical care,” she says. “It’s another thing as to when it’s a billable service.  ”

Surgeons may try to bill these visits without realizing that any preoperative evaluations they conduct after deciding to perform surgery are part of the global surgical package . The global package also includes the visit during which the surgeon performs a preoperative history and physical (H&P). Per CPT guidelines revised in 2016, surgeons can’t bill the H&P separately using modifier -24.

In addition, the global package includes any related subsequent visits that occur prior to the surgery but after the decision. For example, a patient decides to have surgery but then delays for a few months due to scheduling conflicts. The surgeon brings the patient back into the office for an evaluation the day before surgery.

This additional visit is not separately billable, says Jimenez. “The payer says, ‘Okay, we’re paying you for the entire package. Don’t unbundle services we are already paying for,’” she adds. If it’s unrelated to the surgery, it’s separately reportable using a diagnosis that’s also unrelated to the surgery.

3. Report at least 3 different ICD-10-CM diagnosis codes

 Visits for preoperative clearance require ICD-10-CM codes that denote the following information:

• Intent for preoperative clearance (Z01.81x)
• Diagnosis for which the patient is undergoing surgery
• Diagnosis for which clearance is requested

Note that ICD-10-CM code Z01.81x requires additional specificity regarding the purpose of the preoperative exam (i.e., for cardiovascular exam, respiratory exam, laboratory exam, other preprocedural exam, allergy testing, blood typing, or antibody response exam).

Consider this example: a surgeon sends a patient with acute exacerbation of chronic obstructive pulmonary disease (COPD) to a pulmonologist for preoperative clearance so they can undergo knee surgery to alleviate right knee pain due to osteoarthritis. The pulmonologist should report an E/M code for the office visit as well as the following 3 diagnosis codes (in this order):

• Z01.811 (encounter for preprocedural respiratory examination)
• M17.11 (unilateral primary osteoarthritis of the right knee)
• J44.1 (COPD with acute exacerbation)

The code sequence is important because the Z code indicates to payers that the purpose of the visit is for preoperative clearance, says Jimenez. Note that physicians could report more than one Z code depending on the number of systems they evaluate. When reporting multiple Z codes, also remember to report the additional diagnoses for which the examinations and clearance are required.

 For example, an internist might examine the patient’s COPD and cardiac arrhythmia for preoperative clearance. In this case, report Z01.811 as well as Z01.810 (encounter for preprocedural cardiovascular exam). Then report the ICD-10-CM diagnosis codes that denote the reason for surgery. Finally, report the codes for COPD and arrhythmia. 

Further Reading

4. ensure that documentation supports medical necessity.

To justify medical necessity, documentation should include the following details:

• Any condition(s) the physician evaluates to clear the patient for the anticipated surgery
• Whether the patient is cleared for surgery and why
• Reason(s) the patient isn’t cleared for surgery and any action required for clearance (e.g., prescribe a course of antibiotics to treat congestion)

5. Distinguish between “clearance” and “decision for surgery”

Unlike visits for preoperative clearance that require pre op CPT codes, surgeons can bill for visits to discuss the decision for surgery. Report an E/M code with modifier -57 (decision for surgery) when the encounter is the day before or the day of a major surgery. When the encounter occurs prior to the day before surgery, modifier -57 is not required.

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Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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April 28, 2024

Surgical procedures, modifiers, global package

CMS and CPT both define the components of the global surgical package to include certain pre-op, intra-op, and post-op services. Learn what is included in the single payment, what may be reported separately and how to do it.

• Coding Guide – Minor Surgical Procedures
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Simplified guidelines for coding and documenting evaluation and management office visits are coming next year. Learn how to apply the guidelines to some common visit types.

CAROL SELF, CPPM, CPC, EMT, KENT MOORE, AND SAMUEL L. CHURCH, MD, MPH, CPC, FAAFP

Fam Pract Manag. 2020;27(6):6-11

Author disclosures: no relevant financial affiliations disclosed.

Editor's note: In its 2021 Medicare Physician Fee Schedule, CMS released new guidance regarding coding for prolonged E/M services. This article has been updated accordingly.

The American Medical Association (AMA) has established new coding and documentation guidelines for office visit/outpatient evaluation and management (E/M) services, effective Jan. 1, 2021. The changes are designed to simplify code selection and allow physicians to spend less time documenting and more time caring for patients. Physicians and other qualified health professionals (QHPs) will be able to select the level of office visit using either medical decision making (MDM) alone or total time (excluding staff time) on the date of service. In addition, the history and physical exam will be eliminated as components of code selection, and code 99201 will be deleted (code 99211 will not change). (See “ E/M coding changes summary .”)

To follow up on the previous FPM article detailing these changes (see “ Countdown to the E/M Coding Changes ,” FPM , September/October 2020), we have applied the 2021 guidelines to some common types of family medicine visits, and we explain below how documentation using a typical SOAP (Subjective, Objective, Assessment, and Plan) note can support the chosen level of service.

In each vignette, we've arrived at a code based only on the documentation included in the note. It's possible that a more extensive note could support a higher level of service by further clarifying the physician's decision making. But we've analyzed each case through an auditor's lens and tried not to make any assumptions that aren't explicitly supported by the note.

Starting in January, physicians and other qualified health professionals will be able to select the level of office visit using either medical decision making alone or total time (excluding staff time) on the date of service.

Medical decision making is made up of three factors: problems addressed, data reviewed, and the patient's risk. The highest level reached by at least two out of three determines the overall level of the office visit.

If the visit was time-consuming, but the medical decision making did not rise to a high level, the physician or qualified health professional may want to code based on total time instead.

MEDICAL DECISION MAKING (MDM)

Starting in January, physicians will be able to select the level of visit using only medical decision making, with a revised MDM table. (See the table at https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf .)

The four levels of MDM (straightforward, low, moderate, and high) will be maintained but will no longer be based on checkboxes or bullet points. The level of service will be determined by the number and complexity of problems addressed at the encounter, the amount and complexity of data reviewed and analyzed, and the patient's risk of complications and morbidity or mortality.

Here's what that looks like in practice:

STRAIGHTFORWARD MDM VIGNETTE

An established patient presents for evaluation of eye matting. The documentation is as follows:

Subjective: 16 y/o female presents with a 2-day history of bilateral eye irritation. She denies any fever or sick contacts. She started having a slight runny nose and cough this morning. She thinks the matting is a little better than yesterday. She wears daily disposable contacts but hasn't used them since her eyes have been bothering her. Her younger sibling has had similar symptoms for a few days.

Objective: Temperature 98.8, BP 105/60, P 58.

General: No distress. Does not appear ill.

HEENT: Mild bilateral conjunctival erythema without discharge. No tenderness over eye sockets. EOMI, PERRL.

Neck: No cervical lymph nodes palpated.

Lungs: Clear to auscultation.

Assessment: Viral conjunctivitis.

Plan: Reviewed likely viral nature of symptoms. Supportive and conservative treatment options reviewed, including eye cleaning instructions and contact lens precautions. Call the office if symptoms persist or worsen. Avoid use of contacts until symptoms resolve.

CPT code: 99212.

Explanation: Under the 2021 guidelines, straightforward MDM involves at least two of the following:

Minimal number and complexity of problems addressed at the encounter,

Minimal (in amount and complexity) or no data to be reviewed and analyzed,

Minimal risk of morbidity from additional diagnostic testing or treatment.

This is the lowest level of MDM and the lowest level of service physicians are likely to report if they evaluate the patient themselves (code 99211 will still be available for visits of established patients that may not require the presence of a physician).

In this fairly common scenario, the assessment and plan make it clear that the physician addressed a single, self-limited problem (“minimal” in number and complexity, per the 2021 MDM guidelines) for which no additional data was needed or ordered, and which involved minimal risk of morbidity.

Per the 2021 CPT guidelines, “For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated.” In this case, there is little risk of morbidity to this patient from the viral infection diagnosed by the physician.

It's possible the physician considered prescribing an antibiotic in this case, but decided against it. Options considered but not selected can be used as an element for “risk of complications,” but they should be appropriate and documented. There is no documentation in this note to indicate the physician made that decision. The documentation provided, therefore, does not support a higher level of service using MDM. But if the physician did make that decision and the ensuing conversation with the patient was time-consuming, the physician always retains the option to choose the level of service based on time instead.

LOW LEVEL OF MDM VIGNETTE

An established patient presents for follow-up for stable fatty liver. The documentation is as follows:

Subjective: 62 y/o female presents for follow-up of nonalcoholic fatty liver. She has no other complaints today and no other chronic conditions. She denies any fever, weight gain, swelling, or skin color changes. She also denies any confusion. She continues to work at her regular job and reports no difficulties there. She denies any unusual bleeding or bruising. Energy is good. Diagnosis was made three years ago, incidentally, on an ultrasound. Condition has been stable since the initial full evaluation.

Objective: BP 124/70, P 76, Temperature 98.7, BMI 26.

General: Well-appearing. Alert and oriented x 3.

Eyes: Sclera nonicteric.

Heart: Regular rate and rhythm; trace pretibial edema.

Abdomen: Soft, nontender, no ascites, liver margin not palpable.

Skin: No bruising.

Labs reviewed and analyzed: CBC normal, CMP with elevated AST (62 IU/ml) and ALT (50 IU/ml), PT/PTT normal.

Last ultrasound was 3 years ago.

Assessment: Nonalcoholic steatohepatitis, stable.

Plan: LFTs continue to be improved since initial diagnosis and 30-pound intentional weight reduction. Continue monitoring appropriate labs at 6-month intervals. Follow up in 6 months, or sooner if swelling, bruising, or confusion. Avoid alcohol. Continue weight maintenance. She is reassured her condition is stable and has no other questions or concerns, especially in light of her prior extensive education on the topic. I am arranging for hepatitis A and B vaccination. Discussed OTC medications, including vitamin E, and for now will avoid them.

CPT code: 99213

Explanation: Under the 2021 guidelines, low-level MDM involves at least two of the following:

Low number and complexity of problems addressed at the encounter,

Limited amount and/or complexity of data to be reviewed and analyzed,

Low risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one stable chronic illness, which is an example of an encounter for problems low in number and complexity. The risk of complications from treatment is also low. The “Objective” section indicates review of three lab tests, which qualifies as a moderate amount and/or complexity of data reviewed and analyzed. However, the level of MDM requires meeting two of the three bullets above, so the overall level remains low for this vignette.

MODERATE LEVEL OF MDM VIGNETTE

An established patient with obesity and diabetes presents with new onset right lower quadrant pain. The documentation is as follows:

Subjective: 42 y/o female presents for evaluation of 2 days of abdominal pain. She has a history of Type 2 diabetes, controlled. Pain is moderate, 6/10 currently, and 10/10 at worst. The pain is intermittent. The pain is located in the back and right lower quadrant, mostly. She denies diarrhea or vomiting but does note some nausea. She denies fever. She denies painful or frequent urination. She is sexually active with her spouse. She has had a hysterectomy due to severe dysfunctional bleeding. She has not tried any medication for relief. No position seems to affect her pain. She has not had symptoms like this before. Home glucose checks have been in the 140s fasting. Her last A1C was 6.9% two months ago. Family history: Sister with a history of kidney stones.

Objective: BP 160/95, P 110, BMI 36.1.

General: Appears to be in mild to moderate pain. Frequently repositioning on exam table.

HEENT: Moist oral mucosa.

Abdomen: Mild right-sided tenderness. No focal or rebound tenderness. Normal bowel sounds. No CVA tenderness. No suprapubic tenderness. No guarding.

UA with microscopy: 3 + blood, no LE, 50–100 RBCs, 5–10 WBCs.

CBC, CMP, CT stone study ordered stat.

Assessment: Abdominal pain – suspect renal stone. Also consider cholecystitis, gastroparesis, gastroenteritis, appendicitis, and early small bowel obstruction.

Diabetes, type 2, controlled.

Obesity – this is a risk factor for gall-bladder problems, but still favor renal stone.

Plan: Ketorolac 60 mg given in office for pain relief. Hydrocodone/APAP prescription for pain relief. Discussed at length suspicion of renal stone. Will plan lab work and pain control and await CT stone study. Urine sent to reference lab for microscopy. Drink plenty of fluids. Urine strainer provided. Call the office if worsening or persistent symptoms. Await labs/CT for next steps of treatment plan. Will follow up with her if urology referral is indicated.

CPT code: 99214

Explanation: Under the 2021 guidelines, moderate level MDM involves at least two of the following:

Moderate number and complexity of problems addressed at the encounter,

Moderate amount and/or complexity of data to be reviewed and analyzed,

Moderate risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one undiagnosed new problem with uncertain prognosis (abdominal pain) and two stable chronic conditions (diabetes and obesity). Either one (the new problem with uncertain prognosis or two stable chronic conditions) meets the definition of a moderate number and complexity of problems under the 2021 MDM guidelines. But they do not meet the threshold of a high number and complexity of problems, even when combined.

The physician reviews or orders a total of four tests, which again exceeds the requirements for a moderate amount and/or complexity of data, but doesn't meet the requirements for the high category.

The prescription drug management is an example of moderate risk of morbidity. One might argue that the risk of morbidity is high because renal failure could result from a major kidney stone obstruction. But even then the overall MDM would still remain moderate, because of the number and complexity of problems addressed and the amount and/or complexity of data involved.

HIGH LEVEL OF MDM VIGNETTE

An established patient with a new lung mass and probable lung cancer presents with a desire to initiate hospice services and forgo curative treatment attempts. The documentation is as follows:

Subjective: 92-year-old male presents for follow-up of hemoptysis, fatigue, and weight loss, along with review of his recent chest CT. He reports moderate mid-back pain, new since last week. Appetite is fair. He denies fever. He continues to have occasional cough with mixed blood in the produced sputum.

Objective: BP 135/80, P 95, Weight down 5 pounds from 2 weeks ago, BMI 18.5, O2 sat 94% on RA.

General: Frail-appearing elderly male. No distress or shortness of breath. Able to speak in full sentences.

HEENT: No palpable lymph nodes.

Lungs: Frequent coughing and diffuse coarse breath sounds.

Heart: Regular rate and rhythm.

Ext: No extremity swelling.

MSK: Moderate tenderness over multiple thoracic vertebrae.

CT shows large right-sided lung mass suspicious for malignancy, along with a moderate left-sided effusion. Lytic lesions seen in T6-8.

Assessment: Lung mass, suspect malignancy with bone metastasis.

Plan: After extensive review of the findings, the patient was informed of the likely poor prognosis of the suspected lung cancer. We reviewed his living will, and he reiterated that he did not desire life-prolonging measures and would prefer to allow the disease to run its natural course. He also declines additional testing for diagnosis/prognosis. A shared decision was made to initiate hospice services. Specifically, we discussed need for oxygen and pain control. He declines pain medications for now, but will let us know. He and his son who was accompanying him voiced agreement and understanding of the plan.

CPT code: 99215

Explanation: Under the 2021 guidelines, high level MDM involves at least two of the following:

High number and complexity of problems addressed at the encounter,

Extensive amount and/or complexity of data to be reviewed and analyzed,

High risk of morbidity from additional diagnostic testing or treatment.

In this vignette, the patient has one acute or chronic illness or injury (suspected lung cancer) that poses a threat to life or bodily function. This is an example of a high complexity problem in the 2021 MDM guidelines. The physician reviewed one test (CT), so the amount and/or complexity of data is minimal. A decision not to resuscitate, or to de-escalate care, because of poor prognosis is an example of high risk of morbidity, and the physician has clearly documented that in the plan portion of the note. Consequently, even though the amount and/or complexity of data is minimal, the overall MDM remains high because of the problem addressed and the risk involved.

Under the new guidelines, total time means all time (face-to-face and non-face-to-face) the physician or other QHP personally spends on the visit on the date of service. Examples include time spent reviewing labs or reports, obtaining or reviewing history, ordering tests and medications, and documenting clinical information in the EHR.

The AMA has also created a new add-on code, 99417, for prolonged services. It can be used when the total time exceeds that of a level 5 visit – 99205 or 99215. (See “ Total time plus prolonged services template .”)

TIME-BASED CODING VIGNETTE

An established patient presents with a three-month history of fatigue, weight loss, and intermittent fever, and new diffuse adenopathy and splenomegaly. The documentation is as follows:

Subjective: 30-year-old healthy male with no significant PMH presents with a three-month history of fatigue, weight loss, and intermittent fever. He travels for work and has been evaluated in several urgent care centers and reassured that he likely had a viral syndrome. Fevers have been as high as 101, but usually around 100.5, typically in the afternoons. Testing for flu and acute mono has been negative. He denies high-risk sexual behavior and IV drug use. He denies any sick contacts. He has not had vomiting or diarrhea. He has not had any pain. He denies cough.

Objective: BP 125/80, P 92, BMI 27.4.

General: Well-nourished male, no distress.

HEENT: No abnormal findings.

Lungs: Clear.

Heart: No murmurs. Regular rate and rhythm.

Abdomen: Soft, non-tender, moderate splenomegaly.

Skin: Multiple petechia noted.

Lymph: Multiple cervical, axillary, and inguinal lymph nodes that are enlarged, mobile, and non-tender.

Assessment: Weight loss, lymphadenopathy, and splenomegaly

Plan: Prior to the visit, I spent 15 minutes reviewing the medical records related to his recent symptoms and various urgent care visits. We reviewed the differential at length to include infectious disease and acute myelodysplastic condition. I have ordered stat blood cultures, TB test, EBV titers, echo, and CBC. The pathologist called to report concerning findings on the CBC for likely acute leukemia. I called the patient to inform him of his results and need for additional testing. I also discussed the patient with oncology and arranged a follow-up visit for tomorrow. I spent a total of 92 minutes with record review, exam, and communication with the patient, communication with other providers, and documentation of this encounter.

CPT Codes: 99215 and 99417 x 3.

Explanation: In this instance, the physician has chosen to code based on time rather than MDM. The physician has documented 92 minutes associated with the visit on the date of service, including time not spent with the patient (e.g., time spent talking with the pathologist and time spent in documentation). According to the 2021 CPT code descriptors, 40–54 minutes of total time spent on the date of the encounter represents a 99215 for an established patient.

The 2021 CPT code set also notes that for services of 55 minutes or longer, you should use the prolonged services code, 99417, which can be reported for each 15 minutes beyond the minimum total time of the primary service (99215). The difference between the 92 minutes spent by the physician and the 40-minute minimum for 99215 is 52 minutes. There are three full 15-minute units of 99417 in those 52 minutes, so the physician may report three units of 99417 in addition to 99215. CPT 2021 instructs you to not report 99417 for any time unit less than 15 minutes, so the seven remaining minutes of prolonged service is unreportable.

Note that if this had been a new patient, the physician would only be able to report two units of 99417 in addition to 99205. Though the elements of MDM do not differ between new and established patients, the total time thresholds do. The range for a level 5 new patient is 60–74 minutes.

FINAL THOUGHTS

CPT does not dictate how physicians document their patient encounters. As illustrated above, a standard SOAP note can be used to support levels of MDM (and thus levels of service) under the 2021 guidelines.

Physicians who want to further solidify their documentation in case of an audit may choose to make the elements of MDM more explicit in their documentation. This could be particularly helpful for documenting the level of risk, which is the least clearly defined part of the MDM table and potentially most problematic because of its inherent subjectivity. Stating the level of risk and giving a rationale when possible allows a physician to articulate in the note the qualifying criteria for the submitted code. For example, going back to our vignette of moderate MDM, the physician could note in the chart, “This condition poses a threat to bodily function if not addressed, due to acute kidney injury for an obstructive stone.”

It is also worth noting that much of the note in each case is for purposes other than documenting the level of service. For instance, with history and physical exam no longer required, the subjective and objective portions of the note are recorded primarily for continuity or quality of care rather than to justify the level of service. This provides some administrative simplification. What's in the note will become more about what is needed for medical care and less about payment justification under the new guidelines. That's a plus for primary care.

We hope these examples are helpful as you prepare to implement the 2021 CPT changes. You can also visit https://www.aafp.org/emcoding for more resources and information.

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Quality & Practice Resources / Coding and Reimbursement / Patient Pre-optimization Quick Coding Guide

Patient Pre-optimization Quick Coding Guide

This guide will help you accurately code presurgical optimization services. Examples of these types of services include:

• Ensuring the patient is medically fit for surgery (reviewing consults, imaging, and lab results)
• Determining the appropriate location for surgery (IP, OP, ASC)
• Arranging preoperative rehabilitation services
• Perioperative management
• Discharge planning
• Infection screening
• Anticoagulation coordination

*Does not represent a comprehensive list

Quick Guide Print Version

Quickly download and print an easy-to-read PDF of our Patient Pre-optimization Quick Coding Guide.

CMS Definitions of Global Days and Included Services

• No pre-operative period
• No post-operative days
• Visit on the day of procedure is generally not payable as a separate service
• Visit on the day of the procedure is generally not payable as a separate service
• Total global period is 11 days

Count the day of surgery and the 10 days immediately following the day of surgery

• One day preoperative period (is included)
• Day of the procedure is generally not billable as a separate service
• Total global service is 92 days

Count 1 day before the surgery, the day of surgery, and the 90 days immediately following the day of surgery

Appropriate Codes for Reporting Patient Pre-Optimization

Office or other outpatient e/m services.

CPT Code: 99212-99215

Description: Office or other outpatient visit for the evaluation and management of an established patient.

Medical decision making and time criteria varies by code.

Notes: Guidelines for assigning medical decision making (MDM) credit under the current 2021 E/M guidelines for office services may limit the level of service when using MDM for code selection of an optimization visit. For example, if a provider using MDM to select a level of service takes credit for consideration of major surgery under the Risk element during an initial evaluation, it is not clear if the same credit can be assigned when the decision for surgery is finalized.

Using Time to determine the level of service for an optimization visit is reasonable and supported.

Visit #1: A patient with severe knee arthritis refractory to non-operative measures returns to the office. Physical exam and radiographs indicate a total knee (27447, 90-day global) would be the best option and a unilateral knee placement (27446, 90-day global) is being considered. Comorbidities include hypertension, unstable diabetes, and atrial fibrillation which requires an anticoagulant. Patient is sent to see her internist, endocrinologist, and cardiologist for pre-operative clearance consultations.

Visit #2: The patient returns to the office and the provider reviews all of the records and gets up-to-date laboratory values. If the findings from the clearance consultations and laboratory testing indicate the patient is able to proceed with surgery, the provider then proposes surgery as a definitive recommendation. The provider explains the specifics of the proposed procedure and initiates other presurgical optimization steps.

Both of these visits are billable as an established patient office visit E/M code, with the level of the visit determined by the documentation (99212-99215, +99417, +G2212). The global period for the surgery will start the day before the operation. When the surgeon sees the patient the day of surgery prior to the operation that visit is not billable. This is because the preoperative time of that visit has already been valued in the 90-day global code (CPT 27447) as part of the pre-time package.

Prolonged Service With or Without Direct Patient Contact on the Date of an Office or Other Outpatient Service

Code: +99417 (CPT)

Description: Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

Code: +G2212 (CMS)

Description: Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)

Notes: CPT instructions allow prolonged services time on the date of the E/M encounter to be counted after the minimum range of the 99205 or 99215 service is met, but CMS requires that prolonged time is reported after the maximum required time for the primary service.

A provider spends 55-69 minutes (including face-to-face and non-face-to-face services) on the date of an optimization visit. Code +99417 could be reported in addition to code 99215.

For CMS, 70-84 minutes would be required in order to report +G2212 in addition to 99215.

Prolonged Service Without Direct Patient Contact

CPT Code: 99358

Description: Prolonged evaluation and management service before and/or after direct patient care; first hour

CPT Code:  +99359

Description: Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (List separately in addition to code for prolonged service)

• These codes include time spent providing indirect contact services by a physician or other qualified healthcare professional (QHP) in relation to patient management where face-to-face services have or will occur on a different date.
• CPT instructions state that codes 99358 and 99359 cannot be used during the same session as codes 99202-99215, but in the September 2020 CPT Assistant the AMA stated that these codes can be reported for care-related to office or other outpatient services that occurred on a different date.
• In the 2021 Medicare Physician Fee Schedule CMS disagreed and stated they will not allow payment for codes 99358/99359 in relation to codes 99202-99215, even for services on a different date. Other payor rules may vary.
• Time spent providing prolonged services apply to a given date (eg, single date of service), even when time is not continuous. The calculation of time would not include cumulative services provided over multiple dates.
• The CPT coding rule for reporting time-based codes applies (ie. a unit of time is attained when the midpoint has passed).

A provider assessing a patient for surgery documents spending 35 minutes reviewing consultation reports from the internist and endocrinologist, along with laboratory and imaging results, and formulating a plan for surgery. The provider would report code 99358, because greater than the midpoint requirement of one hour was achieved.

At least 30 minutes is required to support code 99358.

Telephone Services

CPT Code: 99441-99443

Description: Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;…

Time criteria varies by code.

Notes: Payor policies for telephone E/M services may vary, particularly during a public health emergency.

A patient who lives a considerable distance away from the provider’s office requests a telephone visit with the provider to discuss the outcome of their presurgical clearance. The provider reviews the consultations and lab results with the patient and determines that the patient is an appropriate candidate for surgery. The call to discuss the perioperative plan and discharge management arrangements takes 30 minutes.

Keep in mind, the CPT definition includes limitations for telephone services originating from or related to a visit within the previous 7 days and leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

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Correct Coding for Pre-operative Clearance

Pre-operative evaluation and testing services may not be covered under Medicare. 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

Pre-operative clearance:

Medicare does not consider all pre-operative 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

Pre-operative medical evaluation:

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 in, the 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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1. How do you code a pre-operative clearance?

To code a pre-operative clearance, use relevant ICD-10 codes reflecting the patient’s condition and reason for surgery.

2. What is the ICD-10 code for pre-operative clearance?

The ICD-10 code for pre-operative clearance falls under Z01.810 to Z01.818, depending on the type of examination.

3. What is the purpose of the Pre-operative assessment?

Pre-operative assessments aim to evaluate a patient’s health before surgery to optimize care and minimize risks.

4. What happens during a medical clearance?

During medical clearance, providers review medical history, conduct exams, and order tests to ensure the patient is fit for surgery.

5. Does Medicare pay for preoperative clearance?

Medicare’s coverage for preoperative clearance varies based on service necessity and coverage policies. Check eligibility before proceeding.

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Pre-Op Visits vs. Pre-Op Clearance Visits: Which are Billable?

August 11, 2023 |  By Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM |  Terry Fletcher Consulting, Inc. | Healthcare Coding and Reimbursement Consultant, Educator and Auditor |  Podcast Host, CodeCast®, NSCHBC Edge Podcast, #TerryTuesday TCG Podcast | NAMAS Educational Speaker and Writer

A question comes up often regarding billing for pre-op visits. Should we? Or shouldn’t we? There is conflicting published guidance on this question from different sources. 

First, this depends on what you mean by “pre-operative visits”. Are you talking about a visit performed by the surgeon (or the surgeon’s QHP) or a provider not involved with the surgery? If the decision is made to perform the surgery during this encounter — whether initial or follow-up — then it is appropriate to report an E&M visit. If the surgery occurs on the same day or the following day, append modifier -57 to the E&M as the decision for surgery modifier. 

However, if the patient is coming in for a “history and physical” or “pre-op” visit to obtain consents and answer questions the patient may have, this encounter is not billable as it is included in the reimbursement for the surgery. In the RVUs for all surgeries with a 90-day global period, there is pre and post-op work included for this encounter. It would be considered “double-dipping” and being paid twice. Many have the opinion that, technically, if this encounter happens two or more days before the surgery, you could bill it, but ethically you probably should not. I would disagree. 

There is no CPT code for a non-billable H&P encounter. Some providers choose to use 99024 to track the frequency and the associated ICD-10-CM codes for these non-billable services. Others use a code they have created, such as pre-op, as a placeholder for these encounters when their EMR allows for it with no dollar figure attached. Other practices don’t track these encounters and may not enter them into the practice management system at all. Now, let’s look at a “pre-op clearance” or surgical clearance encounter that would not be done by the surgeon or the PA/NP practicing under the surgeon. A surgical pre-op clearance is where a specialist (i.e., Cardiologist or Internal Medicine physician) or PCP clears the patient for surgery. For instance, if a patient with CHF (congestive heart failure) is scheduled for a total right knee replacement under general anesthesia, the surgeon and anesthesiologist may request clearance from the patient’s cardiologist. The cardiologist is not performing the surgery and most likely follows the patient for this condition. Therefore, the cardiologist will not be paid for any services included in the global package. The cardiologist should code the pre-operative clearance encounter with the appropriate E&M code and follow the ICD-10-CM guidelines for the encounter. 

These guidelines are in ICD-10-CM General Guidelines: Section IV, Item M “Patients receiving preoperative evaluations only. For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional code. Code also any findings related to the pre-op evaluation.” In the hypothetical case mentioned above, the ICD10-CM codes would be Z01.810, M17.11, I50.9

Another scenario comes up that many coders and physicians attempt to code as a pre-op visit because of the hospital administrative mandate, but you have to determine what the visit is for. Example: Hospitals require that we do an H&P within 30 days of taking a patient to the OR. If this visit is more than 48 hours prior to surgery, is that a billable visit?

Answer: No, the H&P, in this case, is not a billable visit.  This question comes up often and was addressed by AMA CPT® Assistant® in the following excerpt:

“If the decision for surgery occurs the day of or before the major procedure and includes the preoperative evaluation and management (E/M) services, then this visit is separately reportable. Modifier 57, Decision for Surgery, is appended to the E/M code to indicate this is the decision-making service, not the history and physical (H&P) alone. If the surgeon sees the 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. 

Example: The surgeon sees the patient on March 1 and makes a decision for surgery. Surgery is scheduled for April 1. The patient returns to the office on March 27 for the H&P, consent signing, and to ask and clarify additional questions. The visit on March 27 is not billable, as it is the preoperative H&P visit and is included in the surgical package.”

Source: AMA CPT® Assistant, May 2008/Volume 19, Issue 5, pp. 9, 11

CPT® says once the decision is made to proceed with surgery, the subsequent visits related to the procedure (e.g., an H&P, getting consent form signed, answering questions) are included in the 90-day surgical package.  However, in some cases, a patient may be a candidate for a surgical procedure but has a number of medical issues (such as cardiac disease, asthma, or Coumadin [anticoagulant adjustment needed]) that require a medical evaluation to determine if he/she is healthy enough for surgery.  After the patient has had a “medical clearance,” he/she returns to you to review the medical doctor’s evaluation, and you, at that point, decide to proceed with surgery.  This visit may be billed as an E&M visit, as the decision for surgery is just now being made.

One thing to remember is that utilizing mid-level providers in a surgery practice, such as a PA or NP, to provide pre-ops is not billable as they are considered the same specialty and are not providing “medical clearance” but a pre-op to reiterate the original encounter discussion with the surgeon. There is no “medical necessity” for billing an administrative visit for duplicate information to get home health referrals, prescriptions, or disability forms signed. You might have a cash charge, but billing this to an insurance company is a red flag. 

Medicare has weighed in on pre-op visits as well:

• PREOPERATIVE SERVICES A. General.–This manual instruction addresses payment for preoperative services that are not included in the global surgery payment. Sections 4820 and 4821 of the Medicare Carriers Manual (MCM) describe the preoperative care that is included in the global surgery payment. 
• Non-global Preoperative Services.–Consist of evaluation and management (E/M) services (preoperative examinations) that are not included in the global surgical package and diagnostic tests performed for the purpose of evaluating a patient’s risk of perioperative complications and optimizing perioperative care . Medicare will pay for all medically necessary preoperative services as described in §15047, subsections C and D.
• Non-global Preoperative Examinations.–E/M services performed that are not included in the global surgical package for the purpose of evaluating a patient’s risk of perioperative complications and to optimize perioperative care . Preoperative examinations may be billed by using an appropriate CPT code (e.g., new patient, established patient, or consultation). 
• Preoperative Diagnostic Tests.–Tests performed to determine a patient’s perioperative risk and optimize perioperative care. Preoperative diagnostic tests are payable if they are medically necessary and meet any other applicable requirements.

You’ll notice a theme here. CMS is clear that pre-op, whether an E/M visit or diagnostic test, first has to be done to “evaluate the patient’s RISK” for the procedure and then it has to be “medically necessary.” A pre-op that does not address this is not a billable service. It is a routine informed consent visit. 

Your next steps:

• Contact NAMAS to discuss your organization’s coding and documentation practices.
• Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
• Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
• Check out the agenda for the 15 th Annual NAMAS Auditing & Compliance Conference and register to attend!

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Outpatient Visit Current Procedural Terminology Code Level Selection Trends in Hand Surgery Following Criteria Changes by the American Medical Association

Jack g graham.

1 Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA

Kyle Plusch

Michael rivlin, samir sodha.

2 Department of Orthopaedic Surgery, Hackensack University Medical Center, New York, USA

Greg G Gallant

Pedro beredjiklian.

Introduction: Beginning on January 1, 2021, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions with regard to the outpatient evaluation and management (E/M) criteria dictating the Current Procedural Terminology (CPT) code level selection. The primary goal of the current study was to determine how the recent E/M coding criteria changes have impacted code level selection by orthopedic hand surgeons in the outpatient setting.

Materials and methods: All outpatient visits within the hand and wrist surgery division of a single orthopedic practice were collected during two timeframes: March 1, 2019, to June 30, 2019, and March 1, 2021, to June 30, 2021. Procedure codes and insurance categories were collected for each visit. The primary endpoint analyzed was the visit level of care based on CPT E/M codes. For each timeframe, we determined the number of total visits that were coded at each level and expressed them as a percentage of the total visits for that time period. The insurance plan billed for each visit was recorded and classified as Medicare, Medicaid, Workers' Compensation, or commercial.

Results: In 2019, prior to the billing level requirement changes, 7.2% of all visits were billed as level 2, 84.8% of all visits were billed as level 3, and 7.8% of all visits were billed as level 4. In 2021, 1.9% of visits were billed as level 2, 47.3% of visits were billed as level 3, and 50.5% of visits were billed as level 4. Level 1 and 5 visits did not exceed 0.5% in either timeframe. Within each insurance category, the proportion of visit levels of care followed a similar trend of reduced level 2 and 3 visits and increased level 4 visits from 2019 to 2021.

Conclusion: We noted a significant trend toward higher code level selection following the recent code level changes, and we anticipate these recent code selection trends to have major financial implications moving forward.

Introduction

On January 1, 2021, the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions to the outpatient evaluation and management (E/M) criteria dictating Current Procedural Terminology (CPT) code level selection [ 1 , 2 ]. It has been well-documented that physicians spend a disproportionate amount of time working on the electronic health record (EHR), often at the expense of face-to-face time with the patient [ 3 , 4 ]. As a part of their “Patients over Paperwork” initiative, the CMS sought to help diminish administrative burden and simplify the documentation required of physicians to justify code level selection in the outpatient setting [ 1 , 5 , 6 ]. These revisions represented the first major overhaul in E/M coding in over two decades.

These recent changes place the onus of the coding level on the complexity of medical decision-making (MDM) and not on the documentation requirements on the history and physical examination sections of the medical record as had been the case under the previous system [ 2 ]. Physicians now have the flexibility to document the pertinent history and physical examination findings in the EHR “as medically appropriate” to support their MDM. While the CPT codes have remained the same, the level of service (LOS) is now determined by MDM or total time spent by the physician on the date of the encounter. Time spent includes reviewing pertinent data or notes, face-to-face interaction, and time spent documenting or placing orders in the EHR on the day of the encounter only. MDM takes into account the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity/mortality associated with the management of the patient’s conditions [ 1 ]. Under the previous system, the extensive documentation required to reach a higher LOS may have deterred subspecialists from higher-level code selection. These changes are particularly impactful in fields such as hand surgery, where the appropriate history and physical examination can often be especially focused.

The purpose of the current study was to determine how the recent E/M coding criteria changes have impacted code level selection by orthopedic hand surgeons in the outpatient setting. We hypothesized that the new emphasis on MDM would be associated with higher-level CPT code selection by hand surgeons. Given that visit complexity is directly tied to reimbursement, the secondary outcome measured was the number of corresponding relative value units (RVUs) per visit in this same set of patients under the new coding criteria.

Materials and methods

Following Institutional Review Board approval, including a waiver of informed consent per institutional protocol, we performed a billing database search to identify all in-person outpatient visits among 18 fellowship-trained hand surgeons within a single orthopedic practice during two timeframes: March 1, 2019, to June 30, 2019, and March 1, 2021, to June 30, 2021. While the billing level change occurred on January 1, 2021, the year 2020 was not included due to the significant disruption of in-person office visits associated with the coronavirus disease 2019 (COVID-19) pandemic. Patient demographics and procedure codes were collected for each visit, and internal billing records were reviewed to collect the insurance category and plan billed for each visit. Using the Physician Fee Schedule available through the CMS website, corresponding RVUs from 2019 to 2021 were also collected [ 7 ].

The primary endpoint analyzed was the visit level of care based on CPT E/M codes. Historically, many outpatient clinic visits have been billed for using one of 10 five-digit CPT codes, which represent both patient status (new versus established) and visit complexity based on LOS. All new patient visits have been represented by a CPT E/M code 9920_, with the final digit ranging from 1 (low complexity) to 5 (high complexity). Established patient visit E/M codes begin with 9921_, with the final digit also ranging from 1 (low complexity) to 5 (high complexity). The specific criteria for each E/M code selection are described in Table ​ Table1 1 below [ 1 ]. Work RVUs are assigned to each of these E/M CPT codes by the CMS as outlined in their Physician Fee Schedule [ 7 ]. Consults, post-operative visits, and fracture care follow-up (within the global period) have been unaffected by the recent changes by the American Medical Association (AMA) and CMS. Thus, we omitted these patient visits from our analysis.

Table adapted from the 2021 American Medical Association guidelines regarding CPT E/M code changes [ 1 ].

LOS = level of service; E/M = evaluation and management; CPT = Current Procedural Terminology; MDM = medical decision-making.

Starting January 1, 2021, the code 99201 was removed due to historic underutilization, meaning it is no longer possible to code a new patient visit as level 1. For each time period, we determined the number of total visits that were coded at each level and expressed them as a percentage of the total visits for that time period. The insurance plan billed for each visit was recorded and classified as Medicare, Medicaid, Workers' Compensation, or commercial. All categorical variables were compared with chi-square analysis, and continuous variables were compared with a two-sample t-test.

Over the eight months of data collection, there were 34,593 total visits among 26,935 unique patients (Table ​ (Table2). 2 ). From March 1, 2019, to June 30, 2019 period, there were 15,904 outpatient visits; the corresponding period in 2021 had 18,689 visits.

Data are presented as the number of visits (% of that year’s total visits).

LOS = level of service; E/M = evaluation and management; CPT = Current Procedural Terminology.

The proportion of visit billing levels changed substantially from 2019 to 2021. Prior to the billing level requirement changes, the majority of visits were billed as level 3 (84.8%), compared to an almost even split of level 3 and level 4 visits after changes (47.3% level 3; 50.5% level 4). The difference in the number of visits billed at levels 2, 3, and 4 between the two timeframes was significant (p < 0.001). These data are represented in Table ​ Table2, 2 , which also breaks down the levels of care for new patient visits and established patient visits separately.

Insurance data were available for 33,360 (96.4%) of the patient visits and are depicted in Table ​ Table3. 3 . Commercial insurance providers were billed for 64.9% of visits, 24.9% of visits were billed to Medicare, 9.0% of visits were billed to Workers’ Compensation, and 1.2% of visits were billed to Medicaid. Within each insurance category, the proportion of visit levels of care followed a similar trend of significantly reduced level 2 and level 3 visits and greatly increased level 4 visits from 2019 to 2021. Per the CMS Physician Fee Schedule, mean RVUs billed per visit increased significantly (p < 0.001) for all visits, new patient visits, established patient visits, and each insurance category (Table ​ (Table4) 4 ) [ 7 ].

The CPT code system dates back to 1966, one year after Congress created Medicare under the Social Security Act [ 8 ]. The AMA has overseen consistent revisions of the system ever since. In the year 2000, the CPT system was officially named the coding standard for all United States health care [ 8 ]. Today, each CPT code is five digits long and corresponds to nearly any healthcare service that can be billed for [ 5 , 8 ]. These codes are subcategorized into one of the following groups: medicine, surgery, radiology, anesthesia, E/M, pathology, and laboratory. E/M codes are the predominant subcategory utilized in the outpatient setting, including the hand surgery clinic.

Prior to recent changes by the AMA and CMS, the level of complexity for each outpatient visit was determined using a combination of three basic domains: history, physical examination, and MDM. The lowest complexity score (ranging from 1 to 5) of these three domains was used to determine the overall visit LOS. The history and physical examination sections required extensive documentation to meet higher complexity criteria. For example, all level 4 or 5 visits required the following history documentation: four or more elements of the history of present illness (HPI), 10 or more elements of the review of systems (ROS), and past medical, family, and social histories. A level 4 or 5 musculoskeletal examination required documentation of at least 30 bullet points, including specific minimums in each of the following areas: constitutional, cardiovascular, lymphatic, integumentary, musculoskeletal, and neurologic/psychiatric. These do not usually pertain to most hand surgical complaints. A level 3 visit required less ROS elements (two to nine), only a single past medical, family, or social history documented, and only 12 physical examination bullet points.

It is clear that the recent E/M documentation requirement changes made by the AMA and CMS have had a substantial impact on LOS code selection patterns in our hand and wrist surgery division. With the new emphasis on MDM and added flexibility regarding the history and physical examination documentation, our surgeons have consistently selected higher code complexities consistent with the medical complexity in a very focused, subspecialized field of surgery. Taking all patient encounter types into account, we saw a substantial increase in level 4 visits (CPT E/M code 99204 or 99214) from 7.8% in the 2019 study period to 50.5% in 2021. A corresponding decrease in level 3 visits (CPT E/M code 99203 or 99213) from 84.8% in 2019 to 47.3% in 2021 was noted (Table ​ (Table2). 2 ). These trends remained consistent, regardless of insurance type or patient status (new vs. established). Level 2 visits saw a similar decline from 7.2% of all visits in 2019 to less than 2% in 2021. Level 1 and 5 visits remained rare selections at less than 0.5% of all visits.

While CPT coding represents the “common language” for medical procedures and is essential to communication, data collection, and clinical research, this system is also closely tied to reimbursement and valuating healthcare services [ 5 , 8 , 9 ]. The Relative Value Scale Update Committee (RUC), which is made up of select physician representatives from most medical and surgical specialty societies, plays a major role in determining the value of medical services and procedures. Valuation is based on three primary components: physician work, practice expense, and professional liability insurance (PLI) [ 8 - 10 ]. Each year, the RUC is tasked with updating CPT code valuation recommendations to CMS through a strict methodology. The CMS operates under a rule of budget neutrality, meaning that the expansion in reimbursement for one procedure or service may impact the reimbursement of others [ 9 ]. CMS publishes its decisions on any proposed RVU changes and adjusts its annual conversion factor in the Physician Fee Schedule Final Rule each November [ 2 , 7 , 9 ].

As a result of the increase in LOS coding in our practice, there was a notable increase in mean RVUs per office visit in our hand surgery practice. The most substantial increase was noted in established patient visits, which saw an RVU increase of 65.2% on average (0.96 RVUs in 2019 to 1.59 RVUs in 2021). New patient visits had a mean RVU increase of 43.5% from 2019 to 2021. Insurance type did not portend any major differences in RVU increase, as all four sub-categories had significant increases in mean RVUs from 49.1% to 59.8% (Table ​ (Table4 4 ).

Tassavor et al. compared dermatology resident clinic E/M code level selection patterns between two separate two-month periods before and after the recent changes by the AMA and CMS on January 1, 2021 [ 11 ]. After analyzing over 2500 unique patient visits, they reported a similar, but smaller 13% increase in level 4 visits and a 20% decrease in level 2 visits following the recent criteria changes.

Our study has several limitations. There were unprecedented changes in our hand surgery clinic patient flow as a result of the COVID-19 pandemic, requiring a significant amount of telehealth visits [ 12 ]. For this reason, we chose to exclude the year 2020 for analysis and instead chose a four-month pre-pandemic timeframe. However, E/M coding principles prior to January 1, 2021, were mostly unchanged for two decades. While it would have been ideal to compare consecutive years, it is unlikely that our results would have differed significantly. Additionally, this study only represents an individual practice’s patient population in the northeastern United States and may or may not apply to other geographies. While the trend of increased coding complexity and RVUs was widespread across all patient visit types and insurance categories, it could be worthwhile to analyze the percentage of approved reimbursement between these groups. The present study did not investigate this. Finally, while all visit level coding was subject to our practice’s standard auditing process, it remains a possibility that billing errors were made.

Conclusions

It is unknown how uniform these recent coding patterns are among hand surgeons. Individual surgeons and practices may adapt to the regulation changes at different speeds, and LOS selection differences may become even more apparent over time. We suspect that higher complexity code selection since January 1, 2021, will become consistent across the orthopedic subspecialties; however, further investigation in this area is warranted. These findings may have been anticipated by the AMA and CMS following their simplification of documentation guidelines aimed at diminishing the administrative burden on the practicing physician. It remains to be seen what impact these trends have on future reimbursement policies and the healthcare system as a whole. What is clear, however, is that at our institution, since the E/M coding criteria overhaul beginning in 2021, there has been a significant trend toward a higher level of service code selection in hand surgery.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained or waived by all participants in this study. Thomas Jefferson University Institutional Review Board issued approval #22E.229. The Thomas Jefferson University Institutional Review Board has approved this research under IRB control #22E.229 (“New Evaluation and Management Code Level Selection Trends in Outpatient Orthopaedic Surgery Visits”), with a waiver of informed consent per institutional protocol.

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ)

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Computer Science > Computer Vision and Pattern Recognition

Title: surgical-desam: decoupling sam for instrument segmentation in robotic surgery.

Abstract: Purpose: The recent Segment Anything Model (SAM) has demonstrated impressive performance with point, text or bounding box prompts, in various applications. However, in safety-critical surgical tasks, prompting is not possible due to (i) the lack of per-frame prompts for supervised learning, (ii) it is unrealistic to prompt frame-by-frame in a real-time tracking application, and (iii) it is expensive to annotate prompts for offline applications. Methods: We develop Surgical-DeSAM to generate automatic bounding box prompts for decoupling SAM to obtain instrument segmentation in real-time robotic surgery. We utilise a commonly used detection architecture, DETR, and fine-tuned it to obtain bounding box prompt for the instruments. We then empolyed decoupling SAM (DeSAM) by replacing the image encoder with DETR encoder and fine-tune prompt encoder and mask decoder to obtain instance segmentation for the surgical instruments. To improve detection performance, we adopted the Swin-transformer to better feature representation. Results: The proposed method has been validated on two publicly available datasets from the MICCAI surgical instruments segmentation challenge EndoVis 2017 and 2018. The performance of our method is also compared with SOTA instrument segmentation methods and demonstrated significant improvements with dice metrics of 89.62 and 90.70 for the EndoVis 2017 and 2018. Conclusion: Our extensive experiments and validations demonstrate that Surgical-DeSAM enables real-time instrument segmentation without any additional prompting and outperforms other SOTA segmentation methods.

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• Medical Coding
• General Surgery

Wiki   Pre operative visits

• Thread starter pscott
• Start date Aug 16, 2016
• Aug 16, 2016

What is the correct way to code pre operative visits? I've read so much about it that I'm getting confused, especially regarding decision for surgery visits and preoperative clearance visits. Thanks!  

AlaskanCoder

This depends totally on what you mean by "pre-operative visits". Are you talking about a visit to the surgeon (or the surgeon's NPP) or to a provider not involved with the surgery? If the decision is made to do surgery during this visit, then you would code for the appropriate E&M and, if the surgery occurs on the same day or the following day, append modifier -57 to the E&M. However, if the patient is coming in for a "history and physical" and to obtain consents and answer questions the patient may have - this encounter is not billable, as it is included in the reimbursement for the surgery. In the RVUs for all surgeries with a 90-day global period, there is the work included for this encounter. Technically, if this encounter happens 2 or more days before the surgery, you could bill it, but ethically you probably should not. There is no CPT code for a non-billable H&P encounter. Some of my providers choose to use 99024 to track the frequency and the associated ICD-10CM codes for these non-billable services. Others use a code they have created, such as Preop as a place holder for these encounters, when their EMR allows for this. A few just don't enter them into the practice management system at all. A surgical clearance encounter would not be done by the surgeon. A surgical clearance is where a specialist (usually) clears the patient for surgery. For instance, if a patient with CHF is scheduled for a breast biopsy for a suspicious mass under general anesthesia, the surgeon and anesthesiologist may request clearance from the patient's cardiologist. The cardiologist is not doing the surgery, therefore, the cardiologist will not be paid for any services included in the global package. So, the cardiologist should code the pre-operative clearance encounter with the appropriate E&M code and follow the ICD-10-CM guidelines for the encounter. These guidelines are in Section IV item M "Patients receiving preoperative evaluations only. For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional code. Code also any findings related to the pre-op evaluation" So in the hypothetical case I mentioned the ICD10-CM codes would be Z01.810, N63, I50.9 Hope this helps, Karen Hill, CPC, CPB, CPMA, CPC-I AHIMA Approved ICD-10-CM Trainer  

Chelle-Lynn

You may want to review the attached link for the Medicare Learning Network for Global Services which discusses pre-operative services. These are usually a very good resource for clear information when things start to get confusing. In our office, the providers wanted to track how many pre-operative services they were doing that were inclusive to the surgery so we developed an internal "billing" code that allows us to track the services without actually billing a claim. https://www.cms.gov/Outreach-and-Ed...oducts/downloads/GloballSurgery-ICN907166.pdf  

Thanks to both of you for making it cleared!  

graceroni13

• Sep 4, 2016

We actually just had this issue pop up and I'm so happy I found this thread. One of our doctors said that Medicare wouldn't pay for pre-ops, so they were putting a code in that is $0 charge (99024/99025). So one of the coders brought it up to the PA that typically does this doctor's pre-op appointments. So the issue is that these pre-op visits are NOT the decision for surgery, but the PA is spending at least 20 minutes with these patients talking specifically about the surgery and giving them education on everything they need and answering their questions... I understand if they're wanting to include it in the payment for surgery, but is there ANY way we can charge for this ethically? And is this only for Medicare? Or do a lot of insurances follow this? I'm not trying to do anything wrong, but when these patients come in for their MRI results, that's when the doctor decides to proceed with surgery since he can see what's going on, but it's after that that this pre-op visit is happening where it's actually being thoroughly discussed and everything. We're putting the Z01.818 on the visit, but not mod 57 unless it's the day before or the day of surgery. I hadn't heard anything about this until now and want to fully understand what we can do to charge for it without getting in trouble of course, or if it's just a lost cause... I don't want to tell these doctors it's a lost cause and by the way hey, that full day of clinic your PA or NP is having is for free. You know? I've asked another coder and haven't heard back but I want to see what our options are of IF there are any.... I mean they should be paid for the amount of time and education they're giving I would think, but I'm not going to continue charging for these if it's flat out wrong. I mean does the time frame that this happens matter? This PA is doing them at least 3 days prior to the surgery... sometimes it's earlier.  

• Sep 5, 2016

graceroni13 said: We actually just had this issue pop up and I'm so happy I found this thread. One of our doctors said that Medicare wouldn't pay for pre-ops, so they were putting a code in that is $0 charge (99024/99025). So one of the coders brought it up to the PA that typically does this doctor's pre-op appointments. So the issue is that these pre-op visits are NOT the decision for surgery, but the PA is spending at least 20 minutes with these patients talking specifically about the surgery and giving them education on everything they need and answering their questions... I understand if they're wanting to include it in the payment for surgery, but is there ANY way we can charge for this ethically? And is this only for Medicare? Or do a lot of insurances follow this? I'm not trying to do anything wrong, but when these patients come in for their MRI results, that's when the doctor decides to proceed with surgery since he can see what's going on, but it's after that that this pre-op visit is happening where it's actually being thoroughly discussed and everything. We're putting the Z01.818 on the visit, but not mod 57 unless it's the day before or the day of surgery. I hadn't heard anything about this until now and want to fully understand what we can do to charge for it without getting in trouble of course, or if it's just a lost cause... I don't want to tell these doctors it's a lost cause and by the way hey, that full day of clinic your PA or NP is having is for free. You know? I mean they should be paid for the amount of time and education they're giving I would think, but I'm not going to continue charging for these if it's flat out wrong. I mean does the time frame that this happens matter? This PA is doing them at least 3 days prior to the surgery... sometimes it's earlier. Click to expand...

[email protected]

• Sep 8, 2016

Pre Op Exam Hi can you include Chronic conditions in as a 3rd or 4th dx. Example Pt present for preoperative cardiovascular exam. He has a history of htn with moderate ckd. He is scheduled for a total hip replacement for degenerative osteoarthritis of the right hip. Can I code the Z code then the reason for surgery and include the HTNCKD and the stage or only report the z code the reason for surgery and any findings if found? Thanks  

• Nov 2, 2017

[email protected] said: Hi can you include Chronic conditions in as a 3rd or 4th dx. Example Pt present for preoperative cardiovascular exam. He has a history of htn with moderate ckd. He is scheduled for a total hip replacement for degenerative osteoarthritis of the right hip. Can I code the Z code then the reason for surgery and include the HTNCKD and the stage or only report the z code the reason for surgery and any findings if found? Thanks Click to expand...

Contributor

• Mar 23, 2018

CodingKing said: It sounds like standard pre-op to me. Yes, patents have a lot of questions, but what they are discussing has no bearing as to whether the surgery is necessary or not. Now if the operation is cancelled, then it may become billable. They are not providing services free of charge. They are being paid for it through the surgery reimbursement. The surgical RVU includes a pre-op, interop and post-op component. The pre-op component is going to the visit you are describing by the PA The timing of when it's performed doesn't determine if its billable or not. The decision for surgery can be made months in advance.If the visit is unrelated to the surgery, then it can be billed separately, if it's related then no. Global surgery is not a Medicare concept; it's a CPT concept, so it applies to every payer. Click to expand...