What are the preoperative (pre-op) requirements for shoulder surgery using ICD-10 (International Classification of Diseases, 10th Revision)?

From the Guidelines

The preoperative requirements for shoulder surgery should include a combination of paracetamol and an NSAID or a cyclo-oxygenase-2 (COX-2)-specific inhibitor, as well as the consideration of regional analgesic techniques, such as a continuous interscalene block, to minimize postoperative pain and opioid use. When preparing a patient for shoulder surgery, it is essential to consider the most recent and highest quality evidence to prioritize morbidity, mortality, and quality of life as outcomes.

Preoperative Medications

• The use of paracetamol and an NSAID or a COX-2-specific inhibitor is recommended pre-operatively or intra-operatively, and should be continued into the postoperative period, unless there are contra-indications, as supported by the PROSPECT approach to providing recommendations 1.
• The analgesic benefits and opioid-sparing effects of these simple analgesics are well described, making them a crucial part of preoperative care.

Regional Analgesic Techniques

• A continuous interscalene block is favored over a single-shot interscalene block, as it provides more effective and longer-lasting analgesia, reducing the need for supplemental analgesia and minimizing opioid use 1.
• If an interscalene block is not possible, an axillary nerve block with or without suprascapular nerve block is favored over no block or over a suprascapular nerve block alone, highlighting the importance of regional analgesic techniques in shoulder surgery.

ICD-10 Coding

• The ICD-10 code for a pre-operative examination for shoulder surgery is Z01.818, which represents "Encounter for other preprocedural examination," and should be used as the primary diagnosis when a patient is being seen specifically for pre-operative clearance before shoulder surgery.
• A secondary code should be included to specify the condition necessitating the surgery, such as M75.100 for rotator cuff tear, M19.011 for shoulder osteoarthritis, or S43.401A for shoulder dislocation, providing context about the underlying condition requiring surgical intervention. It is crucial to prioritize the patient's current health status, medication review, any necessary laboratory or diagnostic tests, and clearance for anesthesia during the pre-operative visit, ensuring proper documentation and coding for appropriate reimbursement and clear communication among healthcare providers 1.

From the Research

Preoperative Requirements for Shoulder Surgery

The preoperative requirements for shoulder surgery involve a comprehensive assessment of the patient's condition, including pain intensity, functionality, and psychosocial aspects 2. The following are some key points to consider:

• Assessment of shoulder pain intensity and characteristics using specific validated questionnaires 2
• Evaluation of shoulder functionality and psychosocial aspects 2
• Establishment of preoperative and postoperative therapeutic targets, including shoulder pain control, depression and/or nocturnal sleep improvement, opioid consumption adjustment, and substance abuse cessation 2
• Prescription of individualized therapeutic interventions, including nonpharmacologic and pharmacologic interventions 2
• Multidisciplinary patient follow-up, including monitoring of shoulder pain levels, treatment adherence, and mental health status 2

Preoperative Screening and Assessment

Preoperative screening is essential to identify potential risks and complications, including fall risk 3. The following are some key points to consider:

• Preoperative screening for fall risk using functional measures such as gait speed and Timed Up and Go (TUG) scores 3
• Assessment of patient-reported outcomes, including Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Single Assessment Numeric Evaluation 3
• Evaluation of ambulatory status and association with fall risk 3

Preoperative Management and Care

Preoperative management and care involve a range of activities, including patient education, preoperative tests, and clinical assessments 4. The following are some key points to consider:

• Preoperative care refers to the physical and psychosocial care that prepares a patient to undergo surgery safely 4
• Preoperative tests and clinical assessments can be undertaken during a preoperative outpatient appointment, one week or more before surgery takes place 4
• Patient information will also be provided at this time, and nurse specialists or advanced nurse practitioners may lead preoperative outpatient appointments 4

Postoperative Care and Management

Postoperative care and management involve a range of activities, including monitoring and repeated clinical assessments, thromboprophylaxis, and post-operative analgesia 5. The following are some key points to consider:

• Post-operative management of elective surgical patients begins during the peri-operative period and involves several health professionals 5
• Appropriate monitoring and repeated clinical assessments are required to recognize signs of surgical complications swiftly and adequately 5
• Thromboprophylaxis and post-operative analgesia are essential components of postoperative care following shoulder surgery 5