From the Research
The ICD-9 code for a preoperative examination is V72.84, which is used to assess a patient's fitness for surgery. This code is utilized when a patient undergoes a medical evaluation that includes a review of their medical history, current medications, physical examination, and possibly laboratory tests or other diagnostic procedures to identify any conditions that might increase surgical risk 1. The preoperative exam is a crucial step in ensuring patient safety and identifying potential complications that may arise during or after surgery. According to recent studies, a thorough history and physical examination are reliable and inexpensive preoperative screening tools, and routine testing is not always necessary 2, 3.
Key Components of Preoperative Examination
- Review of medical history
- Current medications
- Physical examination
- Laboratory tests or other diagnostic procedures (as needed)
Importance of Preoperative Examination
The preoperative examination is essential in identifying patients who may be at risk for perioperative complications, and it allows healthcare providers to take necessary steps to mitigate these risks. The use of chest radiography in preoperative evaluation, for example, should be selective and based on evidence, as it may not always be necessary 1.
Coding and Documentation
Healthcare providers use the ICD-9 code V72.84 for billing and documentation purposes when the primary reason for the encounter is to clear a patient for an upcoming surgical procedure. It's essential to note that if specific abnormal findings are discovered during the preoperative evaluation, additional diagnosis codes may be required to fully document the encounter. Although the healthcare system has transitioned to ICD-10 coding, where the equivalent code is Z01.810, some legacy systems or historical documentation may still reference the ICD-9 code V72.84 4.