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Z01.818
ICD-10-CM
Surgery Clearance

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

Preoperative Clearance
Pre-op Evaluation

Diagnosis Snapshot

Key Facts
  • Definition : Evaluation to ensure a patient is fit for surgery.
  • Clinical Signs : Normal vital signs, adequate organ function, controlled comorbidities.
  • Common Settings : Preoperative clinics, primary care offices, specialist consultations.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z01.818 Coding
Z01.810

Encounter for preprocedural clearance

Evaluation and clearance for a planned surgical procedure.

Z01.818

Other preprocedural examinations

General pre-op exams and clearances, not otherwise specified.

Z02

Encounter for examination

Encounters for general medical examinations, including pre-surgical.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Surgery Clearance
Preoperative Evaluation
Postoperative Complication

Documentation Best Practices

Documentation Checklist
  • Surgery Clearance Documentation Checklist
  • ICD-10 coding for pre-op clearance
  • CPT codes for pre-surgical evaluation
  • Document specific reason for clearance
  • H&P supporting medical necessity
  • Pre-op risk assessment documented
  • Clearance explicitly stated by provider

Coding and Audit Risks

Common Risks
  • Unspecified Diagnosis

    Lack of specific diagnosis impacting medical coding accuracy and reimbursement for surgery clearance.

  • Unnecessary Clearance

    Performing surgery clearance without clear medical necessity poses compliance and billing risks.

  • Missing Documentation

    Insufficient documentation supporting the need for surgery clearance leads to audit denials and CDI queries.

Mitigation Tips

Best Practices
  • Verify ICD-10-CM, CPT coding accuracy for pre-op clearance.
  • Clear, concise H&P supports medical necessity for surgery.
  • Timely documentation of clearance reduces compliance risks.
  • Standardized pre-op process improves CDI, coding consistency.
  • Regular audits ensure accurate surgery clearance documentation.

Clinical Decision Support

Checklist
  • Verify documented H&P relevant to surgery
  • Confirm labs/imaging results reviewed & signed
  • Check reconciled meds & anesthesia consult
  • Ensure informed consent obtained & documented

Reimbursement and Quality Metrics

Impact Summary
  • Improved coding accuracy for Surgery Clearance leads to higher reimbursement rates and reduces claim denials. Medical billing best practices.
  • Accurate Surgery Clearance diagnosis coding impacts hospital quality reporting metrics, reflecting better patient care and outcomes. Healthcare quality metrics.
  • Proper coding and documentation of Surgery Clearance minimizes compliance risks related to medical billing audits. Hospital compliance reporting.
  • Streamlined Surgery Clearance workflows enhance efficiency, reducing administrative costs and improving revenue cycle management. Revenue cycle optimization.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Verify pre-op H&P completeness
  • ICD-10-CM Z01.818 diagnosis
  • Link clearance to specific surgery
  • Document surgeon's clearance explicitly
  • Check payer guidelines for Z codes

Documentation Templates

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.
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