Inpatient Admission Prior to Surgery (Preop Days)

Number: 0255

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses inpatient admission prior to surgery (preoperative days).

  1. Medical Necessity

    1. Aetna considers inpatient hospital admission on days prior to surgery medically necessary when any of the following criteria is met:

      • A cardiac catheterization or a major surgical procedure scheduled within 24 hours for a child less than 1 year of age which requires intravenous fluids to achieve and maintain adequate hydration prior to the procedure; or
      • A planned major surgical procedure which requires an extensive bowel preparation (GoLytely, laxatives, multiple enemas) in a member with a co-morbidity (e.g., chronic renal failure, elderly individual with muscle wasting and poor nutritional status resulting in a significant weight loss of greater than 10%) whose condition places the individual at high-risk for electrolyte and fluid imbalances and where there is documentation describing why the member could not receive the needed intervention as an outpatient with the assistance of home health as needed, in lieu of hospitalization; or
      • A planned surgical procedure on partially obstructed bowel which requires a slow but extensive bowel preparation preoperatively where there is documentation describing why the member could not receive the needed intervention as an outpatient with the assistance of home health as needed, in lieu of hospitalization; or
      • Close monitoring of blood sugars is required to provide adequate adjustment of regular insulin coverage in preparation for an operative procedure in a brittle insulin-dependent diabetic member (i.e., diabetic individuals who experience large, unpredictable changes in blood glucose, within short periods of time, as a result of very small deviations from schedule) and where there is documentation describing why the member could not receive the needed interventions as an outpatient with the assistance of home health as needed, in lieu of preoperative hospitalization; or
      • Placement of fiducials (small screws) prior to stereotactic brain surgery; or
      • The member has a concurrent medical problem that requires specific inpatient treatment prior to major surgery (defined as craniotomy, laparotomy, median sternotomy, or thoracotomy) to reduce the operative risk or assure a more favorable outcome where such interventions are not available as an outpatient or there is a contraindication to providing such interventions as an outpatient; or
      • The member is scheduled for an open heart procedure requiring cardiopulmonary bypass (cardiac valve replacement or repair, coronary artery bypass grafting) and has unstable angina, congestive heart failure, severe hypertension, or significant ventricular arrhythmias which is not adequately controlled as an outpatient, to include consideration of obtaining home health services to assist with medication management or where there is a contraindication to attempting control of the co-morbidities as an outpatient; or
      • Where there is documentation in the medical record to support that the member requires a medication or fluid intervention which cannot be provided as an outpatient, to include  consideration of alternative sites , such as member's home with home health services, at an infusion center, or at an outpatient clinic or other facility.

    2. Hospitalization Prior to Transplant

      Members awaiting transplants are commonly hospitalized prior to surgery. Hospitalization of such individuals, however, is only considered medically necessary when the member has needs that justify inpatient confinement. The assessment of medical necessity for hospitalization prior to transplant surgery is performed using the same criteria applied to evaluate the medical necessity of hospitalization for other conditions.

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Other CPT codes related to the CPB:
32096 - 32160 Thoracotomy, limited or major
33016 - 33980 Surgery, heart and pericardium
47015 Laparotomy, with aspiration and /or injection of hepatic parasitic (e.g., amoebic or echinococcal) cyst(s) or abscess(es)
49000 - 49002 Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) or reopening of recent laparotomy
61304 - 61576 Craniectomy or craniotomy
61796 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
61797 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure)
61798 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion
61799 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure)
61800 Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)
62121 Craniotomy for repair of encephalocele, skull base
93451 - 93454 Cardiac catheterization

Other HCPCS codes related to the CPB:
A4648 Tissue marker, implantable, any type, each
C1739 Tissue marker, imaging and non-imaging device (implantable)
G0339 Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment
G0340 Image-guided robotic linear accelerator-based sterotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment

References

The above policy is based on the following references:

  1. American Society of Anesthesiologists (ASA). Basic Standards for Preanesthesia Care. Park Ridge, IL: ASA; October 14, 1987.
  2. Arom KV, Emery RW, Petersen RJ, et al. Patient characteristics, safety, and benefits of same-day admission for coronary artery bypass grafting. Ann Thorac Surg.1996;61(4):1136-1139.
  3. Bach DS. Management of specific medical conditions in the perioperative period. Prog Cardiovasc Dis.1998;40(5):469-476.
  4. Becker RC, Ansell J. Antithrombotic therapy: An abbreviated reference for clinicians. Arch Intern Med.1995;155:149-161.
  5. Cygan R, Waitzkin H. Stopping and restarting medications in the perioperative period. J Gen Intern Med.1987;2:270-283.
  6. Kellerman PS. Perioperative care of the renal patient. Arch Intern Med.1994;154:1674-1688.
  7. Kroenke K. Preoperative evaluation: The assessment and management of surgical risk. J Gen Intern Med.1987;2:257-269.
  8. McCallion J, Krenis LJ. Preoperative cardiac evaluation. Am Fam Physician.1992;45(4):1723-1732.
  9. Merli GJ, Weitz HH. Approaching the surgical patient. Role of the medical consultant. Clin Chest Med.1993;14(2):205-210.
  10. Pichette M, Liszkowski M, Ducharme A. Preoperative optimization of the heart failure patient undergoing cardiac surgery. Can J Cardiol. 2017;33(1):72-79.
  11. Schiff RL, Emanuelle MA. The surgical patient with diabetes mellitus: Guidelines for management. J Gen Intern Med.1995;10:154-161.