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How to Accurately Code Pre Operative Clearance ICD 10?4 min read

pre operative clearance icd 10
Accurate pre operative clearance ICD-10 coding helps physicians to get reimbursed for rendering services prior to the surgical treatments.

Pre-surgical evaluations are an essential part of practice for family physicians in the office and the hospital. Similarly, CMS (Centers for Medicare & Medicaid Services) does not demand a medical history and physical assessment before the surgery. However, there are many physicians who want the evaluation before performing surgical treatments. Pre-operative clearance ICD 10 coding helps physicians submit claims to get payments accurately. Further, surgeons need to select the diagnosis and CPT codes for the evaluation of the patients. In most cases, this is done for emergency surgery of the patients in the medical office.

CPT Codes

According to CPT, “A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.” ICD 10 pre-operative clearance is done when the evaluation meets the requirements. Use the following codes according to the scenario:

  • Outpatient codes 99241-99245
  • Inpatient codes 99251-99255 for new or established patients.

There is some level of evaluation and management when it comes to consultation codes. Also, different levels of documentation are required to keep patient records. These records include exams, patient history, and medical decision-making. After documenting these key factors, you can report the consultation codes if the medical records depict the request for evaluation. In addition, practitioners can report consultation codes if the payer accepts these codes.

Pre-Operative Clearance ICD 10

According to the CMS, all the preoperative clearance required by the surgeons is not medically necessary. Similarly, Medicare does not reimburse for these services as a regular process. The surgery clearance ICD 10 and the payments associated with the pre-op procedures are determined by

  • The benefits are covered under the Social Security Act.
  • Diagnosis or treatment is “reasonable and necessary” to improve the functioning of the body.
  • Preventive service covered by the insurance

Diagnosis Codes

Considering the diagnosis for pre-op, there is a subcategory of the code “Z01.81*,” which is described as “Encounter for preprocedural examinations.” The other CPT codes which deal with the preoperative diagnosis are:

  • Z01.810 “Encounter for preprocedural cardiovascular examination”
  • Z01.811 “Encounter for preprocedural respiratory examination”
  • Z01.812 “Encounter for preprocedural laboratory examination”
  • Z01.818 “Encounter for other preprocedural examination”

ICD 10, Z01.818 is the code used in most cases to ensure seamless pre-operative clearance. In addition, the instructions defined under the ICD 10 classification define the findings of the evaluation before surgery. Further, the evaluation before the procedure is essential to ensure reimbursements from payers. Lastly, defining the reasons for the visit of the patients helps to define the procedure in detail.

Consult with Transcure’s Coding Experts

The medical billing and coding team at Transcure knows exactly how to code for pre-op services accurately. Likewise, our revenue cycle experts ensure that surgeons get paid for their services. In addition, we help submit accurate pre-operative clearance ICD-10 codes to help you receive payments on time. Let our professional and certified coders submit claims to optimize your financial performance.

Your Top Questions Answered (FAQs)

What is pre operative clearance?

Pre operative clearance refers to the process of ensuring a patient is medically fit and optimized prior to undergoing a planned surgery or procedure. It involves evaluating potential health risks and addressing any issues that could complicate or delay the planned surgery.

How do I code for pre operative clearance?

The code for pre operative clearance itself is Z01. 12, Encounter for preprocedural examinations. This code should be reported in conjunction with the planned procedure codes.

Can I use a diagnosis code to describe the reason for pre op clearance?

Yes, in addition to the Z01. 12 code you can report diagnosis codes to identify the specific medical conditions or risks being evaluated and optimized as part of the pre op clearance process. Common codes may include codes for hypertension, diabetes, obesity, tobacco or drug use.

How do I code if pre op clearance identifies new risks or issues?

If the pre op clearance uncovers new medical problems, such as anemia or cardiac issues, you would report the diagnosis codes for those conditions in addition to the Z01. 12 code. This provides full reporting of the patient’s medical status.

What documentation is needed to support pre op clearance codes?

Documentation should include details of the planned procedure, any testing, exams or consultations completed as part of the clearance process, and the medical decision clearing the patient for surgery based on evaluation of their current health status and optimization of identified risks.

Fiza Nisar
Fiza Nisar



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