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Pre-op CPT codes: How to properly code preoperative exams

Mastering pre-op coding is crucial. Here are 5 key practices, from patient clearance to ICD-10-CM codes, to ensure accurate billing and avoid denials.

pre op CPT codes

At a Glance

  • Not all patients need pre-op clearance; healthy ones usually don’t.
  • Specialists often perform clearance, but surgeons must avoid billing separately.
  • Report 3 ICD-10-CM codes for pre-op clearance, specifying exam purpose.

On the surface, coding preoperative visits is relatively straightforward. Simply choose the evaluation and management (E/M) code that most accurately represents the medical decision-making and patient acuity.

However, there’s more to it than that. Coders need to understand the nuances of reporting these visits if they want to avoid payer scrutiny, says Raemarie Jimenez, vice president, member and certification development, at AAPC. “It’s one thing to go through the steps for good clinical care,” she says. “It’s another thing as to when it’s a billable service.”

Jimenez provides the following 5 best practices to help coders report preoperative visits correctly using pre op CPT (Current Procedural Terminology ) codes and avoid costly denials.

1. Recognize that not every patient requires pre-op clearance 

The purpose of a preoperative visit is to evaluate a patient’s complicating health condition to determine whether they can withstand surgery. Healthy patients don’t generally require a preoperative visit. Surgeons may evaluate healthy patients to determine whether surgery is necessary. However, they don’t typically need to send these patients to a primary care physician, internist, or specialist to clear them for the surgery.

2. Know who can perform pre-op clearance

Specialists and internal medicine physicians are among those who most often perform preoperative clearance because they’re the ones typically managing the conditions that could affect surgery. They are relevant for pre op CPT codes.

It’s one thing to go through the steps for good clinical care,” she says. “It’s another thing as to when it’s a billable service. ”
Raemarie Jimenez, AAPC

Surgeons may try to bill these visits without realizing that any preoperative evaluations they conduct after deciding to perform surgery are part of the global surgical package. The global package also includes the visit during which the surgeon performs a preoperative history and physical (H&P). Per CPT guidelines revised in 2016, surgeons can’t bill the H&P separately using modifier -24.

In addition, the global package includes any related subsequent visits that occur prior to the surgery but after the decision. For example, a patient decides to have surgery but then delays for a few months due to scheduling conflicts. The surgeon brings the patient back into the office for an evaluation the day before surgery.

This additional visit is not separately billable, says Jimenez. “The payer says, ‘Okay, we’re paying you for the entire package. Don’t unbundle services we are already paying for,’” she adds. If it’s unrelated to the surgery, it’s separately reportable using a diagnosis that’s also unrelated to the surgery.

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3. Report at least 3 different ICD-10-CM diagnosis codes

 Visits for preoperative clearance require ICD-10-CM codes that denote the following information:

  • Intent for preoperative clearance (Z01.81x)
  • Diagnosis for which the patient is undergoing surgery
  • Diagnosis for which clearance is requested

Note that ICD-10-CM code Z01.81x requires additional specificity regarding the purpose of the preoperative exam (i.e., for cardiovascular exam, respiratory exam, laboratory exam, other preprocedural exam, allergy testing, blood typing, or antibody response exam).

Consider this example: a surgeon sends a patient with acute exacerbation of chronic obstructive pulmonary disease (COPD) to a pulmonologist for preoperative clearance so they can undergo knee surgery to alleviate right knee pain due to osteoarthritis. The pulmonologist should report an E/M code for the office visit as well as the following 3 diagnosis codes (in this order):

  • Z01.811 (encounter for preprocedural respiratory examination)
  • M17.11 (unilateral primary osteoarthritis of the right knee)
  • J44.1 (COPD with acute exacerbation)

The code sequence is important because the Z code indicates to payers that the purpose of the visit is for preoperative clearance, says Jimenez. Note that physicians could report more than one Z code depending on the number of systems they evaluate. When reporting multiple Z codes, also remember to report the additional diagnoses for which the examinations and clearance are required.

 For example, an internist might examine the patient’s COPD and cardiac arrhythmia for preoperative clearance. In this case, report Z01.811 as well as Z01.810 (encounter for preprocedural cardiovascular exam). Then report the ICD-10-CM diagnosis codes that denote the reason for surgery. Finally, report the codes for COPD and arrhythmia. 

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4. Ensure that documentation supports medical necessity

To justify medical necessity, documentation should include the following details:

  • Any condition(s) the physician evaluates to clear the patient for the anticipated surgery
  • Whether the patient is cleared for surgery and why
  • Reason(s) the patient isn’t cleared for surgery and any action required for clearance (e.g., prescribe a course of antibiotics to treat congestion)

5. Distinguish between “clearance” and “decision for surgery”

Unlike visits for preoperative clearance that require pre op CPT codes, surgeons can bill for visits to discuss the decision for surgery. Report an E/M code with modifier -57 (decision for surgery) when the encounter is the day before or the day of a major surgery. When the encounter occurs prior to the day before surgery, modifier -57 is not required.

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Lisa Eramo, freelance healthcare writer

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

Reviewed by

Aimee Heckman

Aimee Heckman is a healthcare business consultant with more than 25 years of experience in medical practice management, revenue cycle management, PM/EHR implementation, and business development. As a Certified Professional Biller (CBP) and Certified Physician Practice Manager (CPPM), Aimee has demonstrated success in assisting physicians with maintaining their independence and surviving the ever-changing healthcare business environment.

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