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Preop clearance: consult or transfer of care?

September 2015

Published in the September 2015 issue of Today’s Hospitalist

A READER SUBMITTED A QUESTION about seeing a patient before surgery. The question didn’t include many details, but it did provide a great opportunity to explore some common periop scenarios.

First, when surgeons ask hospitalists to perform a preop exam to “clear” a patient for surgery, can the hospitalists bill for the service? And if they can, should they bill a consult or an initial or subsequent visit? It turns out that the key to answering those questions is the intent of the surgeon’s request.

What’s the intent?
For a service to qualify as a consult, a physician or qualified nonphysician provider (NPP) must ask another physician (or qualified NPP) for his or her advice, opinion, recommendation, suggestion, direction or counsel in evaluating or treating a patient.

The physician making the request “in this case, the surgeon “plans to continue to treat the patient based on the consultant’s advice. The surgeon is asking the hospitalist to evaluate the patient and advise whether or not the patient is medically stable to undergo surgery.

You can bill a consult only if the requesting provider has made a formal request (typically in writing) AND if you as the performing clinician provide a written summary of your findings and recommendations to the one making the request.

If you are the provider requesting a consult, make sure you document your intention to ask for a consult in the progress note of the patient’s medical record. Also, clearly communicate the intent of your request (a consult vs. a transfer of care) to the consultant.

Some examples: “Consult hospitalist for preoperative evaluation and medical clearance for left total knee replacement” or “Request hospitalist to provide medical clearance for patient prior to CABG.”

Billing a consult
If you are being asked to provide a consult, confirm your understanding of the request (consult vs. transfer of care) with the requesting provider. And make it clear in your documentation what service you have been asked to provide and by whom. As an example, “I have been asked by Dr. Doe to evaluate Ms. Smith for medical clearance prior to surgery for left torn rotator cuff.”

Although the Centers for Medicare and Medicaid Services (CMS) did away with inpatient (99251′ 99255) and outpatient (99241’99245) consult codes in January 2010, these codes remain in the CPT Manual and are accepted by many commercial health plans. For patients not covered by Medicare, report the appropriate level of an inpatient consult code for the preop clearance (99251’99255). For Medicare patients, consultants should report an initial hospital visit code (99221’99223) instead.

Why is a formal request so important? Because without a request from the surgeon, a preop service performed within the global surgical period by another physician could be considered part of the global surgical package. Payment for that service may be bundled into the payment for the entire package.

Transfer of care
Now let’s discuss transfer of care. Medical management or transfer of care occurs when the originating physician or qualified NPP requests that another physician (or qualified NPP) assume responsibility for managing the patient’s care for a condition(s) and does not expect to continue to be involved in that treatment.

In the hospital, surgeons often ask hospitalists to manage patients’ medical conditions. In such circumstances, surgeons are not asking hospitalists for their advice or opinion; rather, they are asking hospitalists to provide periop or postop management of some aspect of patients’ medical care.

Say, for example, patient John Doe has just had a femoral-popliteal bypass graft and needs postop management of his insulin-dependent diabetes and COPD. The surgeon directs the hospitalist to take over these aspects of the patient’s care.

If that surgeon had asked the hospitalist to evaluate the patient prior to surgery and advise whether the patient is medically stable to undergo the procedure, the requirements for a consult have been met and the hospitalist can bill a consult.

If, however, the surgeon asks the hospitalist to manage all aspects of the patient’s non-surgical-related care prior to and after surgery, the hospitalist cannot bill a preop clearance as a consult. Instead, hospitalists would typically bill the first encounter with the patient as an initial hospital visit and report all follow-up care as subsequent visits (99231’99233).

Taking over surgery-related care
Then there’s this possibility, although it’s infrequent: A surgeon asks a hospitalist to manage all aspects of the patient’s postop care, including any care directly related to the surgery. The surgeon should append modifier-54 to the surgical procedure code(s) billed to indicate “surgical care only.”

Hospitalists would bill postop surgical care services using the same procedure code(s) as the surgeon but with the modifier -55 for “Post-operative care only.” (Using these modifiers allocates a percentage of the global surgical payment to the surgeon for the actual surgical care and a percentage to the hospitalist for postop surgical care.) As for billing the medical care hospitalists provide to such patients, they should use the appropriate level of subsequent visit codes with the ICD-9 medical diagnoses linked to those services, with the -24 modifier.

When care is transferred, each provider needs to clearly understand which aspect of care has been transferred. Surgeons should document in the progress note their intention to transfer care of a specific problem(s) to another provider. They should also clearly communicate to hospitalists that they are asking you to take over the care and management of the patient for specific problems.

And both parties should clearly understand whether the requesting provider is asking for advice and recommendations (consult) or for either a specific problem to be managed or all postop care to be managed (transfer of care).

Finally, one more bit of advice: Don’t request a consult using a standing order. Insurers may question medical necessity when the requesting provider has not yet seen the patient to determine whether a consult is needed.

For more information on consults, transfers of care, initial and subsequent hospital visits, and splitting global surgical packages, go to the CMS Internet-only Manual 100-4 (Claims Processing Manual), Chapter 12, Sections 36 and 40.

Sue A. LewisSue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience.