The perioperative surgical home requires successful integration of the four phases of care—preoperative, intraoperative, postoperative and post-discharge. A preoperative evaluation clinic can play a key role in enhancing the latter, achieving added and billable value for anesthesiologists in the process.
“Many of us in this room are capable of delivering preoperative care just like hospitalists can, and we are therefore eligible to receive payment for it,” said Thomas R. Vetter, MD, MPH, professor of anesthesiology and perioperative medicine at the University of Alabama at Birmingham (UAB). “It’s important that anesthesiologists demonstrate continued high value to our institutions, or our importance will become smaller and smaller.”
Preoperative Consultation And Treatment
As Dr. Vetter explained at the 2016 American Society of Anesthesiologists (ASA) Practice Management annual meeting, the typical preoperative process involves a surgeon making the decision of when to operate and then posting the case—often as soon as the day before the surgery.
“That’s not realistic or pragmatic,” said Dr. Vetter. “What we’re trying to do is switch the order of this so that we get an opportunity to evaluate and manage these patients earlier in the game.”
With their Preoperative Assessment, Consultation and Treatment Clinic (PACT Clinic), Dr. Vetter and his colleagues at UAB have undergone an evolution in their approach to preoperative clinical care. The first step, said Dr. Vetter, was to develop a preoperative patient risk screening tool.
“You have to figure out locally what’s important to your stakeholders,” he explained. “We undertook a survey of all our anesthesiologists, our nurse anesthetists and surgeons.”
The result was a preoperative consult and clearance questionnaire that contains simple red flags that indicate a need for a PACT Clinic consult and clearance before a definitive surgery date. The questionnaire is completed on a tablet by patients as they are waiting in the surgery clinic and uploaded into the electronic medical record (EMR).
“If a patient has one of the listed conditions,” said Dr. Vetter, “it’s a red flag. The patient is given a tentative surgery date of 21 days later and a priority appointment in PACT Clinic within one day.”
Afterward, the PACT Clinic provides the surgical clinic with the estimated time needed for adequate assessment and treatment, which could be 21 days or only two days. The PACT Clinic appointment itself may be a formal evaluation and management (E&M) code–based preoperative consultation. The figure outlines some of the key elements that support the PACT Clinic concept.
For Dr. Vetter and his team, therapeutic intervention is a big part of the value stream, and preoperative anemia management has become one high-value target.
“Not only does a unit of blood cost somewhere between $750 to $1,000 to acquire,” said Dr. Vetter, “but when you look at downstream morbidity and mortality, it’s $2,000 to $2,500. Allogeneic blood is lifesaving in some occasions, but overall it’s a very expensive proposition.”
He added, “If you can tackle perioperative blood management and reduce transfusion, that will win a lot of favor with your hospital leadership.”
Dr. Vetter and his colleagues have a pilot study underway with the Division of Orthopaedic Surgery at University of Alabama Hospital, in Birmingham.
Coding and Documentation Requirements
Besides downstream benefits for patients and hospitals, preoperative consultation can be an additional revenue source for anesthesiologists—if billing requirements are met.
According to an ASA report entitled “What Anesthesiologists Need to Know About Reporting E&M or TCM,” “management services [that] are beyond the scope of routine preoperative evaluation are separately billable with appropriate documentation.”
In most cases, said Dr. Vetter, these preoperative E&M services will be provided on an outpatient basis and will be reported by Current Procedural Terminology (CPT) codes 99201 through 99205 for a new patient or 99211 through 99215 for an established patient, as defined in the CPT Manual.
Although anesthesiologists also have the opportunity to bill for post-discharge care in the form of Transitional Care Management (TCM) services, Dr. Vetter advised not to start with this additional service.
“Post-discharge care planning is really, really challenging. Anesthesiologists are better off trying to figure out how to tackle preoperative E&M and generate some additional revenue in the process.”
For those wishing to start their own preoperative clinic, a core group of invested physicians is essential, Dr. Vetter pointed out.
“You’re not just going to take someone out of the operating room and successfully put them in a PACT clinic,” he explained. “You need to figure out who wants to be a part of this team.”
An experienced clinic/nurse manager and a core group of autonomous advanced practice nurses are equally central assets. “In order to generate this product,” said Dr. Vetter, “advanced practice nurses have to be able to practice at the top of their license.”
Dr. Vetter also stressed the importance of acquiring outside assistance before starting a clinic. “Do not attempt this on your own,” he cautioned. “A little knowledge is a dangerous thing …. I encourage you to find someone who’s got real expertise in compliance—not just in the perioperative setting.”
Commenting on Dr. Vetter’s presentation, Joseph William Szokol, MD, chairman of the Department of Anesthesiology at NorthShore University Health System, in Chicago, underscored the need for improved financial compensation in this area.
“Right now, most people that have a preoperative anesthesia clinic don’t get paid for it because they don’t know how to bill for it,” said Dr. Szokol. “I think that by using E&M codes, you could actually make some money and make it valuable to your practice.”
He added, “You may also reduce testing and case cancellation, so there are downstream benefits for the hospital. But there should be benefits for the anesthesia group, as well.”
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