Preoperative consults

[BigSib]

This is a question primarily about ethics and professionalism. I get a lot of perioperative consults for various elective surgeries. Would wager about 90% come with requests for specific tests. Some of the surgeons request nearly everything regardless (CBC, CMP, EKG, CXR, etc.), some request less. A good example say for hip or other ortho surgery is requesting MRSA screening via nares - not good evidence out there to do this to say the least. On occasion I'll call to discuss why they want these things and usually it's based upon a predetermined policy their group has for the procedure type rather than patient-specific risk factors.

Have you ever changed this type of culture or do you just order what's recommended every time? I understand the shifting of liability and the focus on cardiac clearance - that's what I'm primarily worried about in the end. But I sometimes wonder why a super low risk patient really needs to see me if they are just going to get all of these tests anyway. If you're consulting me for something I intend to make the recommendations...

I've even gone so far as to do a formal presentation on perioperative cardiac clearance for their teaching rounds. It seemed like new/intriguing information to a lot of the surgeons and PAs that were present. Just airing my grievances I guess.

See this related blog post.

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[Atlas Shrugged]

I never really understood the PCP preoperative consult. I can understand talking to a cardiologist or nephrologist about something specific related to the patient. PCP's just seemed to get dumped on for things the surgeons were too lazy to do. In this case, why doesn't the orthopod just order the nares swab?

 

[deleted87716]

I don't order or perform any routine preoperative tests myself, as they won't be covered by insurance without an appropriate ICD-10 code ("pre-op eval" won't cut it). Furthermore, reimbursement for routine preoperative tests (e.g., CBC, EKG, etc.) is already bundled into the payment that the facility and surgeon will receive. So, if you order them yourself, you're essentially giving the surgeon a freebie (and potentially sticking the patient with the bill).

Now, if there's something I'm concerned about, I'll order diagnostic tests (e.g., stress test, PFTs, etc.) These will be covered by insurance because they can be billed with the code for the underlying medical condition(s) (e.g., CAD, COPD, etc.)

It's rare that I encounter a referring surgeon who doesn't already know this.

 

[VA Hopeful Dr]

I don't order or perform any routine preoperative tests myself, as they won't be covered by insurance without an appropriate ICD-10 code ("pre-op eval" won't cut it). Furthermore, reimbursement for routine preoperative tests (e.g., CBC, EKG, etc.) is already bundled into the payment that the facility and surgeon will receive. So, if you order them yourself, you're essentially giving the surgeon a freebie (and potentially sticking the patient with the bill).

Now, if there's something I'm concerned about, I'll order diagnostic tests (e.g., stress test, PFTs, etc.) These will be covered by insurance because they can be billed with the code for the underlying medical condition(s) (e.g., CAD, COPD, etc.)

It's rare that I encounter a referring surgeon who doesn't already know this.

Must be nice

 

[cabinbuilder]

I only ever did those in residency. Never in reality.

 

[smq123]

I only ever did those in residency. Never in reality.

I think that you are an exception. In my practice, I do at least one pre-op clearance a week, if not more. I do not know of any family practice doctors who do NOT see pre-op clearance requests routinely.

I also agree with VA Hopeful; many of the referring surgeons do NOT seem to know this.

I take it as an opportunity to catch anything that might doom the surgery, because I have seen many surgeons (predominantly ortho) who do not seem able or willing to do a reasonable H&P. I have had ortho surgeons send me patients for pre-op in preparation for major joint replacements who have had multiple cardiac stents, with no stress test done since. Or the patient who had had a leaky cerebral aneurysm 6 months before (actually started to stroke out in my office), who the surgeon was going to take for a hip replacement.

 

[cabinbuilder]

I should clarify that I have done some pre-op stuff out of residency, as locums you don't generally have to do those and I have never had a practice long enough to have had to do them. Now as exclusive urgent care I never do them.

 

[Bacchus]

I don't order testing unless something came back on the "necessary" testing from the labs/tests ordered by the surgeon. I will do the EKG if asked for, in most cases, but will let the surgeon know it's not necessary. I learned, when on ophthalmology, that certain institutions have certain requirements. One surgicenter was requiring EKGs on every cataract patient. Talk about a waste of $$$.