Find comprehensive information on pre-operative assessment, including clinical documentation requirements, medical coding guidelines, and healthcare best practices. Learn about pre-op evaluation, surgical risk assessment, patient optimization, and pre-admission testing. This resource covers essential aspects of pre-surgical clearance, medical history review, physical examination documentation, and laboratory testing protocols for optimal pre-operative care. Explore details on anesthesia consultations, medication reconciliation, and informed consent procedures relevant to pre-operative assessment and planning.
Also known as
Preoperative cardiovascular exam
Encounter for preop cardiovascular examination.
Other preop cardiovascular exam
Encounter for other specified preop cardiovascular exams.
Other preprocedural examinations
Encounter for other specified preprocedural examinations.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the assessment for a specific procedure?
Yes
Is there a complication?
No
Do not code a pre-operative assessment. Code the reason for the encounter.
When to use each related code
| Description |
|---|
| Pre-operative Assessment |
| Postoperative Diagnosis |
| Complication of Surgical Procedure |
Lack of specific pre-op diagnosis details leads to inaccurate coding and potential underpayment. CDI can clarify.
Pre-existing conditions impacting surgery risk may be unlinked, affecting DRG assignment and reimbursement. Coding review crucial.
Incomplete pre-op history documentation can hinder accurate risk assessment and proper E/M coding. Compliance audits essential.
Pre-operative assessment completed for scheduled surgical procedure. Patient presents for pre-surgical clearance and optimization. Medical history reviewed including current medications, allergies, past surgical history, and relevant family history. Surgical risks assessed and discussed with the patient. Physical examination performed, including vital signs, cardiovascular, pulmonary, and neurological systems. Laboratory results reviewed including complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation studies (PT/INR, PTT), and urinalysis. Electrocardiogram (ECG) obtained and reviewed. Patient's functional status and American Society of Anesthesiologists (ASA) physical status classification documented. Anesthesia risks evaluated and discussed, including airway assessment and potential for post-operative nausea and vomiting (PONV). Pre-operative instructions provided, including NPO guidelines and medication management. Informed consent obtained for the planned surgical procedure. Patient deemed optimized for surgery and cleared for the scheduled procedure. Pre-operative diagnosis consistent with the indication for surgery. Plan includes continuing current medications as directed and following pre-operative instructions. Follow-up scheduled post-operatively. Surgical clearance documentation completed and available in the electronic health record.