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Preoperative Clearance

  1. What requirements must be met for a preoperative clearance visit to be considered medically necessary and billable?

    Answer:
    CMS does not set requirements for medical clearance; these are established by individual hospitals based on current standards of care. However, hospital requirements cannot override Medicare regulations prohibiting screening tests. These visits may be payable by Medicare, but the medical necessity for the clearance must be evident. The necessity is determined by the scope and potential risks of the procedure itself, along with the patient’s general state of health and possible risk factors.

    For a patient with a chronic, stable condition(s) who is undergoing a surgical procedure which is not inherently associated with high risk (e.g., cataract surgery), a preoperative clearance may not be medically necessary. Alternatively, that same patient who is undergoing a more complicated procedure (e.g., elective CABG) may require more detailed preoperative evaluation. When a patient has known preoperative risks (e.g., uncontrolled diabetes or poorly controlled hypertension), a preoperative evaluation may be medically necessary. Please remember, for major surgical procedures, the pre-operative services performed by a surgeon represent anywhere from 8% to 17% of the global fee, depending on the type of surgery. Thus unless there really is a valid medical reason for the pre-operative clearance, the service is not covered by Medicare. Of note, these percentages were determined by CMS, and not by any Medicare contractor. Updated 8/29/2017
     
  2. During a preoperative clearance visit, what is the correct way to count the number of problems addressed, including both the acute problem and any chronic conditions?

    Answer:
    All conditions addressed during the clearance visit should be counted, including both the acute condition and any chronic conditions which must be evaluated in order to safely clear the patient for surgery. Updated 8/29/2017
     
  3. When a patient comes in for a preoperative clearance exam and has a stable chronic illness(es), if the patient has a complete ROS and an exam of all organ systems would this be considered a 99214 visit?

    Answer:
    E&M services are performed based on medical necessity for each element of care, which is reliant upon the provider’s clinical assessment of the patient’s status. A stable, chronic illness alone does not support the need for a detailed history and examination; this must be supported by the provider’s judgment that these details are necessary in order to safely clear the patient for surgery. Updated 8/29/2017 

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Preoperative Clearance
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