Reporting a Preoperative Clearance – Points to Note

by | Last updated Dec 8, 2023 | Published on Jul 25, 2017 | Medical Billing

Preoperative Clearance
Share this:

Primary care physicians are often asked to evaluate a patient prior to surgery at the request of the surgeon. Patients at an advanced age and those with significant medical problems face increased risk for surgical morbidity and mortality, and preoperative evaluation will depend on the extent of the patient’s condition and the type of surgery. There are certain points that need to be noted when reporting a pre-op work-up. In fact, medical billing and coding companies are well aware that evaluation and management (E&M) services before surgery can be denied reimbursement if reported incorrectly. Insurance carriers will pay only if they determine the services to be “medically necessary.”

A primary care physician’s preoperative evaluation of a patient scheduled for surgery will include:

  • History – documentation of the past medical history, a review of current symptoms, a list of medications, allergies, past surgical history and family history
  • Physical exam – height, weight, vital signs, and documentation of any abnormal findings on exam of the entire body
  • Assessment – a list of medical problems and a plan for each problem identified

Following the preoperative evaluation, the primary care physician will have a clear picture of the outpatient condition of the patient. This will make it possible to confirm whether the patient would require any additional diagnostic workup prior to the surgery.

A preoperative history and physician (H&P) is included in the surgical package and should not be reported separately. However, these services can be billed separately if the patient has medical conditions that require separate preoperative clearance and management that go beyond the standard H&P. This could occur if the patient develops a new medical condition or notable change of status, in the days prior to surgery. In this case, the appropriate E/M service level should be reported, linked to the key components of history, exam, and medical decision-making. To establish medical necessity for the visit, documentation should include any new diagnosis or patient problems.

Medicare does not consider all pre-op clearance to be medically necessary and will not routinely reimburse these services. For instance, Priority Health states on their website that some pre-operative evaluation and testing services may not be covered under Medicare or Priority Health Medicare, and that coverage and payment is determined by whether or not the service is:

  • A covered benefit identified in the Social Security Act (SSA)
  • Not specifically excluded from Medicare by the SSA, and
  • “Reasonable and necessary” for the diagnosis or treatment of an illness or injury or to improve functioning of a malformed body member, or
  • A covered preventive service

When billing for the service when the patient’s condition requires the additional evaluation, the provider should submit the claim choosing the most accurate E/M service to reflect the level of services provided.

According to an article published by the Georgia Academy of Family Physicians in 2016, documentation when billing a preoperative medical evaluation should include the following:

  • Reference to the request for a preoperative medical evaluation
  • The specific medical condition that the family physician was asked to address during the preoperative evaluation (such as from a cardiovascular or respiratory point of view)
  • Proof that that the physician has returned his/her opinion and recommendations to the requesting provider

All claims for preoperative evaluations should be reported using the appropriate ICD-10 code: Z01.810 – Z01.818

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

Additionally, the claim should include the appropriate ICD-10 code for the condition to describe the reason for the surgery. For example, suppose a patient who has diabetes and hypertension comes in for preoperative examination for carpal tunnel surgery on the right wrist and the surgeon has ordered laboratory tests. The procedures involved are as follows:

  • Document the requesting provider’s name and the reason for the preoperative medical evaluation.
  • Forward a copy of the findings of the evaluation and management service and recommendations to the surgeon clearing the patient for surgery.
  • Assign diagnosis code Z01.812 for the primary diagnosis.
  • The secondary diagnosis should be the reason for the surgery: G56.01, Carpal tunnel syndrome, right upper limb.
  • Code any other diagnoses and conditions affecting the patient related to the preoperative evaluation. For instance, depending on the patient’s condition, other findings to be reported may be: E11.9, controlled, type 2 diabetes and hypertension: I10, hypertension, benign.

A recent AAPC blog points out that the primary care physician can bill for the standard preoperative care if the surgeon reduces his package payment. However, Medicare does not support regular breaking of the surgical package. Unless geographic distance or other factors prevent the patient from reasonably receiving preoperative care from the surgeon, the preventable extra costs and risks caused in processing two claims (one for the surgeon and one for the primary care physician) would be regarded as abuse by Medicare.

Experienced AAPC-certified coders in a medical billing and coding company are well-informed about the nuances involved in submitting claims for pre-operative evaluations. The will scrutinize physician documentation and assign the right codes to prevent denials and ensure optimal reimbursement for providers.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

More from This Author