How Do You Code Preoperation Evaluations

How Do You Code Preoperation Evaluations

Most pre-op exams will be coded with Z01. 818. The ICD-10 instructions say to use the preprocedural diagnosis code first, and then the reason for the surgery and any additional findings. Evaluations before surgery are reimbursable services.

What is the CPT code for preop evaluation?

For PCP, your primary dx would be Z01. 818, secondary dx the reason for surgery, then any additional for other patient problems. Your CPT would be outpatient E/M 99201-99215 depending on new/established, and level of care.

What is the correct code assignment for a visit with a sole purpose of preoperative evaluation?

81, Encounter for pre-procedural examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.

Alexander Ross
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Alexander Ross

Alexander Ross has covered the video game industry for a decade, writing deep dives on game design, esports tournaments, VR developments, and gaming culture.