Preoperative Testing: Dogma or Dilemma

Preoperative Testing: Dogma or Dilemma

As many of you know, most patients having surgery must undergo a preoperative evaluation by the facility at which the surgery will be performed.

Depending on the surgery, that could be as simple as a staffer obtaining a list of current medications and allergies. But for many other surgeries, the requirements are much more stringent. Many require an evaluation by a medical doctor to determine the patient’s stability for surgery.

Depending on the patient’s medical history and the planned surgery, the evaluation may be performed by their primary care physician or a specialist such as a cardiologist or pulmonologist. Most facilities have a list of tests that must be obtained prior to the surgery.

Prior to my current life as whatever I am now, I was an internist with an office practice. I did my best to keep up with the medical literature. When I got requests for preop clearance, at first I was obedient and did what was asked of me, performing a full history and physical and ordering all the requested tests. But sometime around the turn of the century, a large study was published demonstrating that preop testing for patients undergoing cataract surgery was unnecessary. It did not lower risk, it did increase cost, and it occasionally led to a cascade of costly testing that found nothing.

After that, I started to rebel. When I got a request for one of my patients, I simply wrote “The patient has a beating heart and the ophthalmologist states they have a cataract that warrants extraction. They may proceed without any further evaluation.” And of course, I did not bill for that visit.

So, why am I mentioning this? Well, recently a question came up on a revenue integrity forum about claims being denied for preoperative testing. And as I was looking into it, I found an online document from Noridian titled “Screening Services.” It included a discussion about preoperative testing since that does meet the definition of screening services, in many cases: searching for conditions that are not known to exist, but which may result in an adverse outcome.

Now, the reason I mention this document is because of Noridian’s blunt language that just has to be admired. In the section titled “Reasons for Performing or Ordering a Service or Test,” Noridian obviously lists those reasons. Their list starts with signs, symptoms, past history, abnormal findings, and screening, all of which are commonly cited.

But then Noridian goes for it, listing the following: defensive medicine, error, habit, faulty reasoning, curiosity, patient demand, and finally, financial gain. As Noridian states, “Reasons 7 through 12 are not justifying reasons, i.e., they do not justify the service as either diagnostic or screening. They explain why the physician ordered or gave the service (I goofed, I always do it, I was mistaken, I was curious, the patient insisted, I am greedy), but do not justify the service.”

Now, I don’t know if the Centers for Medicare & Medicaid Services (CMS) approved Noridian calling doctors greedy, but I give them credit for saying the quiet part out loud. But honestly, I think the most common reason preoperative testing is done is dogma, and because simply doing what is requested is the path of least resistance. And in today’s healthcare environment, no one has the energy to fight yet another battle. Be sure to check back next week as I name my 2023 “Hirsch’s Heroes.”

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Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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