From the Research
The ICD-10 code for preoperative evaluation is Z01.818, which is used for encounters specifically for pre-procedural examinations. This code should be used when a patient is being seen for a preoperative evaluation before a planned surgery or procedure. It's essential to note that this code should be listed as a secondary diagnosis, with the condition requiring surgery typically listed as the primary diagnosis. For example, if a patient is being evaluated before gallbladder surgery, you would code K80.20 (cholelithiasis) as the primary diagnosis and Z01.818 as the secondary code. When documenting preoperative evaluations, be sure to include details about the planned procedure, any risk factors identified, and recommendations for perioperative management, as suggested by recent studies on perioperative hypertension management 1, 2. Some key points to consider in preoperative evaluation include:
- Assessing the patient's blood pressure and overall cardiovascular risk, as highlighted in studies on hypertension and surgery 3, 2
- Evaluating the patient's individual risk factors and developing a personalized plan for perioperative management, as recommended by studies on perioperative care 1, 4
- Using the correct technique for blood pressure measurement, as emphasized in studies on hypertension guidelines 1 This coding is essential for proper reimbursement and accurate medical record keeping, as it clearly identifies the purpose of the encounter as preparation for a surgical procedure rather than treatment of an acute condition.