Preoperative Clearance for Anesthesia: Possibilities and Perils

Sure, they sound good. The come-ons and sales pitches that permeate our daily lives are certainly enticing; the rationale they employ can be quite alluring; but the bill of goods we're being asked to buy doesn't always turn out as advertised. That's why caution and discernment are essential tools for today's consumer. This principle of caveat emptor ("let the buyer beware") must especially apply to those in the healthcare community. Unlike the individual who simply endures a bit of frustration after purchasing a defective product, when a medical provider buys into a non-compliant process or practice, it can have serious ramifications—to include negative government action.

Healthcare providers will sometimes attend conferences and hear vendors or consultants who assure them that they can increase their cash flow or add to their revenue stream by simply following their full-proof strategies. Sometimes, the advice may be sound; but, all too often, we've seen examples of medical professionals being led down the primrose path to the land of denial. That is, their new-found revenue strategies were ultimately deemed by payers to be medically unnecessary or otherwise improper. Over the years, we have been made aware that certain consultants have pushed the practice of providing preoperative clearances on a routine basis. In today's article, we will take a closer look at that practice and offer our own caveats.

Defining Our Terms

A preoperative clearance (also known as pre-surgical screening) involves a service that is presumably above and beyond the pre-anesthesia assessment—the latter being bundled into the anesthesia service and thus not separately payable. Depending on the protocol employed by the group or the hospital, the screening is typically performed to determine the patient's fitness to undergo anesthesia or perhaps other physical parameters. Typically, when a member of the anesthesia group performs these screenings, he or she does so with the intention of being paid.

While such screenings may be payable in certain cases where patient conditions warrant the additional service, routinely providing a preoperative clearance in all your scheduled cases is not recommended. Indeed, an older version of the Medicare Claims Processing Manual (MCPM), Ch 12, Sec 30.6.10(G), contained this statement on the topic of preoperative screenings:

Preoperative consultations are payable for new or established patients performed by any physician or qualified NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening. [Emphasis added.]

While this section is no longer part of the MCPM, as Medicare no longer recognizes consultation codes, it does provide insight on Medicare's historical thinking on this issue. "Routine" is one of those compliance watchwords that continues to creep up in government guidance. If it's not medically necessary in all cases, you want to avoid the routine application of such services.

A Case in Point

To demonstrate the risk that a group takes on in this regard, we would point you to U.S. v. Chen—a False Claims action brought against an anesthesiologist for submitting a high-level consultation in connection with each of his anesthesia cases. Ultimately, the jury found that he submitted over 3,500 claims inappropriately.

To be fair, the facts elicited in this case demonstrated that Dr. Chen failed to obtain consult requests relative to these patient encounters. As you will recall, you cannot bill a consult unless there is documentation in the record that the patient's provider requested your evaluation of the patient for the purpose of generating an opinion based on your particular area of expertise. So, for example, a heart surgeon may in the days leading up to the surgery ask you to see his/her patient to determine if the patient will be able to withstand the effects of anesthesia. In the above-entitled case, Dr. Chen failed to follow these documentation requirements.

All this raises the question: was Dr. Chen convicted only because he failed to properly obtain and document the consults, or was he convicted because he performed consults on every one of his cases? Perhaps, either one of these factors would have sealed the good doctor's fate. While the decision does not provide us a clear answer, the conviction still stands as a potential indicator of the risk one takes on by engaging in this type of practice. So, again, while some preoperative consultations may be medically necessary, one should avoid doing them routinely.

Society Standard

In 2014, the Chair of the Committee on Economics for the American Society of Anesthesiologists (ASA) wrote an article, outlining the circumstances under which preoperative clearance services should and should not be billed. They are as follows:

• *The service must be significantly above and beyond the usual pre-anesthesia evaluation; and, as such, would need to address items that are not addressed in the routine pre-anesthesia evaluation.
  
  
• *The conditions examined could include a comprehensive exam of the patient's entire medical condition, as well as management of those issues that need to be corrected or optimized prior to surgery.
  
  
• *These visits would be billed "under rare conditions."
  
  

Under rare conditions is another way of saying that anesthesia providers should avoid billinging for a preoperative clearance on a routine basis.

Suggested Protocol

To ensure that you do not take on unnecessary risk in this area, we suggest you consider creating a group policy that outlines the circumstances under which a preoperative clearance would be performed. For example, you might consider the following protocol:

• *The anesthesia provider must have received a written order by the surgeon requesting an anesthesia consult and containing the reason for the consult.
• *The anesthesia provider should write a consult report (not using the pre-anesthesia assessment form), outlining his/her findings or opinion, referencing the requesting surgeon and making sure the report is placed in the patient record.
• *The anesthesia provider will avoid providing this service on a routine basis for every surgical patient and should consider consult requests only for patients with a physical status of ASA III or higher.

Groups may want to make use of the above protocol examples or generate their own. Our primary desire is to help you receive payment for medically necessary services you perform, while simultaneously shielding you from unwarranted risk. If you have further questions on preoperative clearance, please contact your account executive or reach out to us at info@anesthesiallc.com.