Q. Can diagnosis code V72.8 (pre-op exam) be used by a general physician or just a surgeon? If used by a general physician would the secondary diagnosis be the reason for the surgery or the condition the physician is actually seeing the patient in clearance for (DM, CHF, COPD, etc)?
A. It is not uncommon for a patient to be referred back to his/her primary care physician for clearance prior to surgery for chronic conditions that may impact patient response during/after surgical procedures. Per Medicare Part B News #233: The E&M level of service (LOS) should be billed with the ICD-9-CM diagnosis code of the problem or illness for which the service was requested, as well as the applicable pre-operative V code (V72.81-V72.84), reflecting the patient’s preoperative status. Typically the code of the specific surgical problem is not used. For example, in a patient hospitalized to undergo a cholecystectomy with underlying problems of hypertension and congestive heart failure, the E&M services of a needed non-surgical physician addressing these two latter problems would be billed with the ICD-9-CM codes for hypertension (e.g. 401.9) and congestive heart failure (e.g. 428.0) and the preoperative code V72.83 (Other specified preoperative examination). The code for cholecystitis would commonly not be used for these services. It must not be used in this situation as the only diagnosis.