For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, 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.
Usually, a surgeon will want a preoperative clearance performed by the patient’s primary care provider, often due to a chronic or preexisting condition. When the primary care provider reports the diagnosis for this visit, the first-listed diagnosis will be the appropriate Z code to indicate the encounter is for preop clearance;
then the reason for the upcoming surgery is reported followed by the condition requiring the clearance. The Z code will be one of the following:
Z01.810 Preoperative cardiovascular examination
Z01.811 Preoperative respiratory examination
Z01.812 Preoperative laboratory examination
Blood and urine tests prior to treatment or procedure
Z01.818 Other preprocedural examination
Preoperative evaluations only
When the only service is a preoperative examination, report the appropriate Z code along with any codes that indicate significant conditions.
Coding examples
Patient is seen by cardiologist for surgical clearance for upcoming cataract surgery. The patient has coronary artery disease (CAD) and has a history of angioplasty and cardiac stent. Patient’s medical condition from a cardiac standpoint is stable. Patient can proceed with cataract removal.
ICD-10 codes; Z01.810 preoperative cardiovascular examination, H26.9 cataract
I25.10 coronary artery disease, Z95.5 Presence of coronary angioplasty implant and graft
Patient is seen by internist for medical clearance for inguinal hernia repair. The patient has a number of chronic medical conditions, including hypertension, diabetes type 2, and chronic atrial fibrillation.
ICD-10 code;
Z01.818 other specified preoperative examination,
K40.90 inguinal hernia,
I10 hypertension,
E11.9 diabetes type 2,
I48.2 chronic atrial fibrillation.