Coding Guidance Offered on Surgeon’s Coding of Preoperative Patient Optimization

Both the American Medical Association (AMA) and the American Association of Orthopaedic Surgeons (AAOS) have recently provided guidance and updates on the use of new Current Procedural Terminology (CPT) codes to capture non–face-to-face work performed by surgeons, including spine surgeons.

In the May 2021 issue of AAOS Now, the AAOS addressed correct coding for work performed prior to surgery. Various codes from the Evaluation & Management (E/M) Services section of the CPT code set were referenced, specifically office or other outpatient E/M codes (CPT 99212-99215). The May 2021 article reiterated what is included in the global period and was based on reporting codes to capture the physician work involved in direct interaction with the patient in the office or via telephone, electronic medical record communication, or email.

Then, a November 2022 issue of the American Medical Association’s (AMA’s) CPT Assistant further addressed this topic in a coding brief titled “PCM Codes for Preprocedural Optimization.” In the article, the AMA states that principal care management (PCM) codes (CPT codes 99424-99427) are the appropriate codes for reporting presurgical optimization management services for non–face-to-face and indirect interactions with the patient.

In a February 2023 AAOS Now article, more information on correct coding was described. The article discusses the appropriate CPT codes to report non–face-to-face and indirect services for preoptimization and provides an example of a relevant scenario in orthopaedics. The example is not for spine surgery, but the concept applies to spine surgery codes as well.

According to both the AMA and the AAOS, orthopaedic surgeons may use code 99424, Principal care management services, for a single high-risk disease, with the following required elements:

• one complex chronic condition expected to last at least three months and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death
• the condition requires development, monitoring, or revision of a disease-specific care plan
• the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities
• ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or qualified healthcare professional (QHP), per calendar month

The guidance describes that after the initial hour, surgeons would use code 99425 for each additional 30 minutes provided personally by a physician or other qualified healthcare professional, per calendar month (list separately in addition to code for primary procedure.)

There are an additional two codes for clinical staff work and time. Code 99426 is the primary code for the first 30 minutes of clinical staff time directed by a physician or other QHP, per calendar month. Code 99427 is the add-on code for each additional 30 minutes. The required elements for these codes are the same as for codes 99424 and 99425.

According to the February 2023 AAOS Now article, patient presurgical optimization requires ongoing communication with a care team, coordination of management of comorbidities (e.g., diabetes, hypertension), advocacy of lifestyle changes (e.g., smoking cessation), and adjustment of medications as needed. The article continues to state that the guidance provided in the CPT Assistant brief confirms that the work spent by physicians to establish, implement, and monitor these care plans can and should be reported.

Lastly, according to the CPT Assistant November 2022 guidance, physician work performed in the 24-hour period prior to surgery is considered the beginning of the global period for the procedure and is therefore included in the global surgical package.

If an ISASS member would like more information and guidance on these codes, please contact Matthew Twetten at matthewtwetten@gmail.com

To read the AAOS Now article, see link here.