HCFA Prohibits Carrier's Automatic Denials of Pre-op Evaluations

(6/20/01) In a change to the Medicare Carriers Manual claims processing instructions, HCFA has prohibited carriers from automatically denying claims for preoperative evaluations as of June 30, 2001 (Program Transmittal 1707 published on May 31, 2001 ). Specifically, this Transmittal informs carriers that they must delete all edits for preoperative diagnosis codes V72.81 through V72.84, which includes "preoperative cardiovascular examination." HCFA further instructs the carriers that they must delete all edits that automatically identify such claims for manual review.

HCFA further notes that Medicare will provide coverage for:

• All medically necessary preoperative evaluation and management services that are properly documented, excluded form the global surgery payment, and performed "for the purpose of evaluating a patient's risk of perioperative complications and optimizing preoperative care" (and that, of course, meet all other applicable requirements.
• All preoperative diagnostic tests that are medically necessary and performed to determine the risk the surgery poses to the patient IF the tests are performed to "optimize perioperative care" and meet other applicable requirements.

Preoperative evaluation denials has been identified as one of HCFA's seven major billing hassles that need to be resolved. In this case, HCFA found that it could address the issue by issuing a directive, which has been accomplished. The underlying logic appears to be that medically necessary preoperative evaluations that are performed by, or at the request of, the attending surgeon, do not meet the Social Security Act's definition of non-covered "routine physical checkups."

Coding Requirements

HCFA notes that all claims for preoperative evaluations must be accompanied by the appropriate ICD-9 code (e.g., V72.81 (preoperative cardiovascular evaluation)). Additionally, the appropriate ICD-9 code for the condition(s) that prompted surgery must also be documented on the claim. Finally,
document other diagnoses and conditions affecting the patient as
appropriate. However, the ICD-9 code that appears in the line item of a preoperative evaluation (i.e., CPT for the appropriate E&M or diagnostic test) must be the code for the appropriate preoperative examination (i.e., V72.81 through V 72.84).

Full Text of Program Transmittal 1707 (PDF, 27K)

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