Preoperative services, Medicare

Applies to:

Medicare Advantage and Original Medicare plans

Definition

Care given before surgery when physical and psychological preparations are made for the operation, according to the individual needs of the patient. (Medicinenet.com)

Medicare preoperative services coverage

Some pre-operative evaluation and testing services may not be covered under Medicare or Priority Health Medicare Coverage and payment is 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 functioning of a malformed body member, or
  • A covered preventive service.

Preoperative examination coverage

Not every patient needs to have a preoperative examination separate from evaluation by the surgeon. Medicare does not pay for routine preoperative clearance for surgery.

However, some For reference purposes only, see the first paragraph on this article by WPS-Medicare for a general statement about Medicare preoperative clearance for surgery.

Preoperative examination billing

Payable:

  • When patients have co-morbidities or other diagnoses that require additional evaluation by a professional
  • When medical necessity is documented
  • When a pre-service determination from Priority Health, if necessary, finds the services covered

Not payable:

  • When exam is "routine" vs. medically necessary
  • When billed with codes that do not support medical necessity, such as Z01.810, Z01.811, Z01.812, Z01.818 (encounters for pre-procedural exams)

Preoperative testing coverage

The determination of coverage for preoperative testing being reasonable and necessary starts with applicable National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). All claims submitted to Priority Health are subject to applicable NCDs or LCDs.

NCDs for some commonly performed tests include:

  • Partial thromboplastin time (PTT) NCD 190.16
  • Prothrombin time (PT) NCD 190.17
  • Iron serum labs NCD 190.18

Go to the index for National Coverage Determinations (NCDs) by Chapter/Section Index. Scroll down to 190: Pathology and Laboratory, and click expand (+) to find a listing of Medicare covered pathology and laboratory tests.

If you are still not sure if a test will be covered

Request a pre-service organization determination (PSOD) from Priority Health to prevent costs going to provider liability. Go to PSOD rules and process.

Preoperative testing billing

Payable:

  • When tests are "reasonable and necessary" based on the member's condition and according to NDC, LCD, or a Priority Health PSOD
  • When billed with the most accurate E&M service that reflects the level of service you provided
  • When billed with the correct GA or GY modifier according to Priority Health Medicare GA and GY modifier rules

Not payable:

Certain routine preoperative tests often do not meet the definition of "reasonable and necessary." Examples include:

  • Electrocardiograms or radiological tests, when there is no medical indication for them
  • Partial thromboplastin time (PTT) or prothrombin time (PT), when there are no signs or symptoms of bleeding or thrombotic abnormality or personal history of bleeding, thrombosis conditions associated with coagulopathy
  • Serum iron studies, when there is no indication of anemia or recent autologous blood collections prior to surgery.