From the Research
The ICD-10 code for a preoperative history and physical examination is Z01.810 (Encounter for preprocedural examinations, unspecified). This code should be used when documenting a preoperative H&P that is performed prior to a planned procedure or surgery. When using this code, it's essential to also include the code for the condition that necessitates the surgery as the primary diagnosis, with Z01.810 as a secondary code. For example, if the patient is having gallbladder surgery for cholelithiasis, you would code K80.20 (Calculus of gallbladder without cholecystitis without obstruction) as the primary diagnosis and Z01.810 as the secondary diagnosis.
Importance of Preoperative H&P
The preoperative H&P is crucial for assessing surgical risk, determining anesthesia approach, and identifying any conditions that might require special management during the perioperative period, as emphasized by studies such as 1. A thorough history taking and physical examination of all patients before surgery seems important until more evidence-based guidelines become available, as noted in 2.
Coding Approach
This coding approach ensures proper documentation of both the reason for the surgery and the preoperative evaluation. It is also in line with the recommendations from various studies, including 3 and 4, which highlight the importance of a tailored preoperative assessment based on the patient's medical status and the nature of the proposed procedure.
Recent Guidelines and Studies
Recent studies, such as 1, have questioned the utility and value of conducting a preoperative H&P within 30 days of surgery for low-risk patients, suggesting that de-implementation of this requirement may increase convenience for patients and providers and improve value in surgery. However, the coding for preoperative H&P remains essential for documentation and billing purposes, regardless of the timing or the perceived value of the H&P in certain cases.
Key Points for Coding
- Use Z01.810 for preoperative H&P.
- Include the primary diagnosis code for the condition necessitating surgery.
- Z01.810 is used as a secondary code.
- This approach is supported by the need for thorough preoperative evaluation as discussed in 5 and the importance of proper documentation for patient care and administrative purposes.