Find information on surgery clearance, including preoperative evaluation, medical clearance for surgery, perioperative risk assessment, surgical risk stratification, and obtaining surgical clearance documentation. Learn about the importance of accurate clinical documentation, ICD-10 codes for pre-operative evaluations, and optimizing medical coding for surgical procedures. This resource provides guidance on healthcare protocols related to pre-surgical clearance and optimizing the patient journey for a safe and efficient surgical experience.
Also known as
Encounter for preprocedural clearance
Evaluation and clearance for a planned surgical procedure.
Other preprocedural examinations
General pre-op exams and clearances, not otherwise specified.
Encounter for examination
Encounters for general medical examinations, including pre-surgical.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the clearance for a specific surgery?
Yes
Is there a complicating condition?
No
Is it general medical exam?
When to use each related code
Description |
---|
Surgery Clearance |
Preoperative Evaluation |
Postoperative Complication |
Lack of specific diagnosis impacting medical coding accuracy and reimbursement for surgery clearance.
Performing surgery clearance without clear medical necessity poses compliance and billing risks.
Insufficient documentation supporting the need for surgery clearance leads to audit denials and CDI queries.
Patient presents for preoperative clearance for [Surgical Procedure name, e.g., elective cholecystectomy]. The patient reports [Current Symptoms, e.g., being generally healthy and asymptomatic]. Past medical history includes [List medical history, e.g., hypertension, hyperlipidemia]. Current medications include [List medications, e.g., lisinopril, atorvastatin]. Surgical history includes [List surgical history, e.g., appendectomy]. Family history is significant for [List family history, e.g., coronary artery disease]. Allergies include [List allergies, e.g., no known drug allergies]. Physical examination reveals [Physical exam findings, e.g., a well-developed, well-nourished individual in no acute distress. Cardiovascular exam reveals regular rate and rhythm. Lungs are clear to auscultation bilaterally. Abdomen is soft and non-tender]. Review of systems is [Review of systems findings, e.g., otherwise unremarkable]. Based on the patient's medical history, physical examination, and review of systems, the patient is deemed [Optimized for surgery phrase, e.g., medically optimized for the planned procedure]. [Specify level of clearance, e.g., Surgical clearance is granted]. Recommendations include [Preoperative instructions, e.g., continuing current medications, NPO after midnight the night before surgery, and following standard preoperative protocols]. Patient education provided regarding [Specific education topics, e.g., surgical risks, benefits, and alternatives]. Patient verbalizes understanding. Follow-up as needed postoperatively. ICD-10 code Z01.818 (Encounter for preprocedural consultation) and CPT code 9921[Level of service 2-5 based on documentation] billed for this preoperative evaluation.