Find comprehensive information on preoperative evaluation, including clinical documentation requirements, medical coding guidelines, and healthcare best practices. Learn about preoperative clearance, risk assessment, surgical risk stratification, patient optimization, and perioperative care. This resource covers essential topics for healthcare professionals involved in preoperative planning and documentation, ensuring accurate and compliant medical coding for optimal reimbursement. Explore resources related to CPT codes, ICD-10 codes, and pre-anesthesia evaluation.
Also known as
Encounter for preprocedural exam
Encounters for pre-op exams and evaluations.
Preoperative cardiovascular exam
Exam for cardiovascular clearance before a procedure.
Exam, pre-admission, observation
Pre-admission and observation exams, not otherwise specified.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the evaluation for a specific surgery?
Yes
Is there a complication?
No
Do not code a preoperative evaluation. Code the reason for the encounter.
When to use each related code
| Description |
|---|
| Preoperative Evaluation |
| Preoperative Anemia |
| Preoperative Hypertension |
Separate coding of individual evaluation components when a comprehensive preoperative evaluation code is applicable leads to overbilling.
Using unspecified preoperative evaluation diagnosis codes when more specific codes are available reduces reimbursement accuracy.
Lack of documentation supporting the necessity and extent of the preoperative evaluation can raise audit red flags and compliance issues.
Preoperative evaluation performed for upcoming [Surgical Procedure Name] scheduled on [Date of Surgery]. Patient presents for assessment of perioperative risk and optimization. Relevant medical history includes [List Medical Conditions e.g., hypertension, diabetes mellitus type 2, hyperlipidemia]. Current medications include [List Medications e.g., lisinopril, metformin, atorvastatin]. Surgical history includes [List Surgical Procedures e.g., appendectomy, cholecystectomy]. Allergies include [List Allergies e.g., penicillin, latex]. Review of systems is significant for [Pertinent Positives and Negatives related to the planned surgery, e.g., occasional shortness of breath with exertion, denies chest pain]. Physical examination reveals [Key Findings related to the planned surgery, e.g., clear lung fields, regular heart rate and rhythm, abdomen soft and non-tender]. Patient’s current functional status is described as [Description of Functional Status e.g., ambulates independently, performs activities of daily living without assistance]. Assessment of cardiovascular risk factors includes [Specific Risk Factors and their Status e.g., controlled hypertension, optimized blood glucose levels]. Pulmonary evaluation including [Pulmonary Function Tests or Assessment if performed, e.g., recent chest x-ray unremarkable]. Laboratory results include [Pertinent Lab Values e.g., complete blood count within normal limits, basic metabolic panel unremarkable]. Electrocardiogram results [ECG findings if performed and relevant, e.g., normal sinus rhythm]. Assessment and plan include [Recommendations for Preoperative Management, e.g., continue current medications, NPO after midnight prior to surgery, pre-surgical skin preparation instructions provided]. Patient demonstrates understanding of the perioperative plan. Cleared for surgery with the following recommendations [Specific recommendations, e.g., cardiology consultation recommended prior to major vascular surgery, optimized glycemic control recommended prior to surgery]. This preoperative evaluation supports medical necessity for the planned procedure based on current clinical guidelines. ICD-10 code Z01.818 (Encounter for preprocedural consultation and evaluation) is appropriate for this encounter.