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Pre-Anesthesia Evaluation, Pre-Surgery History & Physical, and Separately Reported E/M Services: Know the Difference

Pre-Anesthesia Evaluation, Pre-Surgery History & Physical, and Separately Reported E/M Services: Know the Difference

While the recent changes to office or other outpatient evaluation and management (E/M) coding and billing guidelines may not affect anesthesiologists most of the time, there are instances when knowing the new rules will come in handy, especially with patients who have complex medical co-morbidities.

In a recent Timely Topics article, the American Society of Anesthesiologists outlined how to distinguish between a pre-anesthesia evaluation, which is required for all anesthesia patients, and a separately reportable evaluation and management service, which happens occasionally with patients for whom “it may be medically necessary to optimize underlying medical conditions, perform care coordination, and/or develop medical optimization transition or bridging orders for patient safety and optimal outcomes.” We’ll highlight the basic differences here, but for a more detailed understanding, be sure to review the ASA’s detailed guide.

The Pre-Anesthesia Evaluation

For all patients who receive anesthesia care, an anesthesiologist must determine the medical status of the patient and develop a plan of anesthesia care prior to the procedure. While the evaluation should be conducted within 48 hours prior to the procedure, the rules do allow the evaluation to be conducted up to 30 days before the procedure when necessary, with an update within 48 hours prior to procedure.

The evaluation should include the following:

  • Reviewing the available medical record.
  • Interviewing and performing a focused examination of the patient to:
    • Discuss the medical history, including previous anesthetic experiences and medical therapy.
    • Assess those aspects of the patient’s physical condition that might affect decisions regarding perioperative risk and management.
  • Ordering and reviewing pertinent available tests and consultations as necessary for the delivery of anesthesia care.
  • Ordering appropriate preoperative medications.
  • Ensuring that consent has been obtained for the anesthesia care.
  • Documenting in the chart that the above has been performed.

According to federal Medicare regulations, “Only individuals qualified to administer anesthesia can perform the elements of a preoperative anesthesia evaluation as described above and this evaluation cannot be delegated to others.” Reimbursement for these services is paid as part of the anesthesia base units and is not separately billable.

Pre-Operative or Pre-Procedural History and Physical Examination

In addition to the pre-anesthesia evaluation, patients also must have a pre-operative history and physical examination.

This additional service also includes a review of medical history, the current medical condition requiring the surgery or procedure, a physical examination, and the development of a surgical or procedural plan. It can be conducted by any physician or qualified healthcare professional in accordance with health system bylaws and state and federal law. 

The surgeon or a member of the surgeon’s staff typically would perform this assessment, which is paid as part of the surgical bundle and is not separately billable. 

Complex Patient Evaluation and Management Service

Finally, some complex patients undergoing surgery or procedures may require medically necessary evaluation and management beyond the scope of the pre-anesthesia evaluation and the pre-operative history and physical examination. For instance, patients may need additional tests and prescriptions to optimize underlying medical conditions, or the anesthesiologist may have to perform care coordination and/or develop medical optimization transition or bridging orders for patient safety and optimal outcomes. 

In these circumstances, the anesthesiologist can bill for his services using an appropriate E/M code. With changes to the office or Other outpatient (99202-99215) E/M codes that began on January 1, 2021, selecting the right level of service is dependent on medical decision making or time. The new guidelines are available from the American Medical Association.

Learn More

For more information about the various services offered to patients prior to a surgery, be sure to review the ASA’s Timely Topic: Distinguishing Between a Pre-Anesthesia Evaluation and a Separately Reportable Evaluation and Management Service, which includes documentation guidelines, illustrative vignettes to help you decide how to report and bill for your own services, and telehealth considerations.

Other resources that also may help, include:

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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