From the Research
The ICD-10 code for a preoperative examination is Z01.810 (Encounter for preprocedural examinations). This code should be used when a patient is seen specifically for a preoperative evaluation before a planned surgery. When coding a preoperative exam, it's essential to also include any secondary diagnosis codes for the condition requiring surgery and any other relevant conditions that may affect surgical risk. For example, if the patient is having a preoperative exam for knee replacement surgery due to osteoarthritis, you would code Z01.810 as the primary diagnosis and M17.9 (Osteoarthritis of knee, unspecified) as a secondary diagnosis. This approach provides a complete clinical picture for billing purposes, as supported by recent guidelines 1. The preoperative exam code helps distinguish these visits from regular office visits, ensuring proper reimbursement and accurate medical record documentation.
Key points to consider when coding preoperative exams include:
- The specific condition requiring surgery should always be documented alongside the preoperative exam code
- Secondary diagnosis codes should be included for any relevant conditions that may affect surgical risk
- The history and physical examination remain the central components of preoperative risk assessment, as emphasized in studies such as 2 and 3
- Routine laboratory testing is not usually beneficial and is costly, as noted in 1 and 4
- Targeted testing based on a thorough history and physical examination is recommended, as supported by 5 and 4
By following these guidelines and using the correct ICD-10 code, healthcare providers can ensure accurate documentation and reimbursement for preoperative exams, while also prioritizing patient care and safety.