The preoperative consult: A coding quiz
Preop visits present unique coding and documentation challenges. To test your knowledge, take this quiz.
QUESTION 3: True or false: Outpatient consults for established patients require 2 components of an encounter.
Answer: B False. Unlike other outpatient E/M codes, the consultation codes require that all 3 components of an encounter—history, examination, and medical decision making—be provided and documented for the appropriate level of service for both new and established patients (TABLE 1).
All 3 must be included in an inpatient consultation as well.
QUESTION 4: What’s the primary diagnosis code for a preop consult?
Answer: C V codes for preop exams (V72.81-V72.84) should be used as the primary diagnosis. In general, V codes are used “on occasions when circumstances other than a disease or an injury justify an encounter with the health care delivery system or influence the patient’s current condition.”2 The 4 allowable V codes for preoperative visits are:
- V72.81 (preop cardiovascular exam)
- V72.82 (preop respiratory exam)
- V72.83 (other specified preop exam)
- V72.84 (unspecified preop exam)
The acute or chronic medical condition for which the patient requires surgery should be listed as the secondary ICD-9-CM code.3 Additional codes may be used for the patient’s other acute or chronic medical conditions.
QUESTION 5: When is a comprehensive exam required?
Answer: A A level 4 (99244) office consult requires a comprehensive exam level; a level 3 (99253) inpatient consult does not.
The 1997 E/M guidelines4 specify that a level 4 office consult in which a general multisystem examination is conducted requires a comprehensive level—with documentation of 2 exam points from each of 9 systems (for a total of 18 points) and performance of all exam points in those 9 systems. The level 3 inpatient consult and level 4 established patient office visit codes require only a detailed exam, which entails documentation of 12 or more of the allowable exam points. Although the 1995 E/M guidelines can be used as a source to ensure that all the requirements are met, the 1997 guidelines are much more specific about the documentation needed for each exam level.
When to conduct a single-system exam. While family physicians frequently use the requirements of the general multisystem exam to determine their level of coding, the CPT rules allow the option of performing certain single-organ system exams. Because the cardiovascular system is the most common concern with a preop consult, it is often easier, and more appropriate, to document the elements of the cardiovascular system exam (TABLE 2) than the general multisystem exam.
In this instance, the V code (V72.81, preop cardiovascular exam) would be used for diagnosis. For patients with COPD or other respiratory problems, it would be appropriate to document the elements of the respiratory system exam (V72.82) instead (TABLE 3).
TABLE 2
The cardiovascular exam: What’s included*
| SYSTEM/BODY AREA | ELEMENTS |
|---|---|
| Constitutional | • Measurement of any 3 of the following 7 vital signs: 1) sitting or standing BP 2) supine BP 3) pulse rate and regularity 4) respiration 5) temperature 6) height 7) weight • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) |
| Head and face | |
| Eyes | • Inspection of conjunctivae and lids |
| Ears, nose, mouth, and throat | • Inspection of teeth, gums, and palate • Inspection of oral mucosa with notation of presence of pallor or cyanosis |
| Neck | • Examination of jugular veins • Examination of thyroid |
| Respiratory | • Assessment of respiratory effort • Auscultation of lungs |
| Cardiovascular | • Palpation of heart (eg, location, size, and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4) • Auscultation of heart, including sounds, abnormal sounds, and murmurs • Measurement of BP in 2 or more extremities when indicated Examination of: • Carotid arteries (eg, waveform, pulse amplitude, bruits, apical-carotid delay) • Abdominal aorta (eg, size, bruits) • Femoral arteries (eg, pulse amplitude, bruits) • Pedal pulses (eg, pulse amplitude) • Extremities for peripheral edema and/or varicosities |
| Chest (breasts) | |
| Gastrointestinal (abdomen) | • Examination of abdomen with notation of presence of masses or tenderness • Examination of liver and spleen • Stool sample for occult blood from patients being considered for thrombolytic or anticoagulant therapy |
| Genitourinary (abdomen) | |
| Lymphatic | |
| Musculoskeletal | • Examination of the back with notation of kyphosis or scoliosis • Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs • Assessment of muscle strength and tone, with notation of any atrophy and abnormal movements |
| Extremities | • Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler’s nodes) |
| Skin | • Inspection and/or palpation of skin and subcutaneous tissues |
| Neurological/psychiatric | Brief assessment of mental status, including • Orientation to time, place, and person • Mood and affect |
| BP, blood pressure. | |
| * What you are required to do: | |
| Level of exam Perform and document Problem focused: 1-5 elements identified by a bullet Expanded problem focused: ≥6 elements Detailed: ≥12 elements Comprehensive: Perform all elements, document every element in each shaded box and ≥1 element in each unshaded box. | |
| Source: American Medical Association; 2008.1 | |
