Preoperative Optimization Visits

Family physicians are often asked to perform pre-procedural or preoperative (“preop”) optimization evaluations. This type of visit attempts to stratify the patient’s risk in advance of a procedure.  The risk is determined by an accurate evaluation of the patient’s health status compared with the inherent risk of the surgery. Online risk stratification tools may be helpful. These visits also attempt to reduce the risk of the procedure by optimizing medical care and addressing medications prior to the procedure.

Documentation

There are 4 key elements that must be documented if consultation codes are used (and should be in your documentation regardless of which codes you use):

1.     Who requested the consult

2.     Why the consult is being performed

3.     What services were provided/recommended

4.     Where the results of the evaluation were routed

Four outcomes are possible and should also be documented:

1.     Proceed with surgery as planned (patient already optimized)

2.     Modification of risk factors; proceed with surgery after risk factor optimization

3.     Delay surgery until further testing is completed

4.     Discuss alternatives to planned surgery 

Note: It’s important to avoid use of the word “clearance” in your note, which implies lack of risk.  Instead, it’s better to list the patient as at low, moderate, or high risk of cardiovascular or other complications.

ICD-10 Diagnosis Codes

For the diagnosis of the visit, use ICD-10 codes from subcategory Z01.81 Encounter for preprocedural examinations.  These include: 

●      Z01.810 Encounter for preprocedural cardiovascular examination

●      Z01.811 Encounter for preprocedural respiratory examination

●      Z01.812 Encounter for preprocedural laboratory examination

●      Z01.818 Encounter for other preprocedural examination

Most pre-op visits will be coded with Z01.818 (Encounter for other preprocedural examination). You should use the preprocedural diagnosis code first, then include the ICD-10 code for the reason for the surgery, followed by any additional findings or diagnoses. Surgeons may send a list of requested labs or radiology studies with the patient. If you order any testing, use the ICD-10 codes that correspond to the testing you order.

Outpatient CPT Consultation Codes

In most cases, the family physician will already have an established relationship with the patient and will bill the visit as a routine office visit. That said, there are outpatient consultation codes which may be used. CMS doesn’t cover consultation codes and other payers may be confused about why the patient’s primary care physician is billing a consultation code. However, if reimbursed, outpatient consultation codes do have higher RVU value than the equivalent routine office visit. 

Note: If you use outpatient consultation codes, the same Medical Decision-Making complexity rules apply, but you must also document a History and Physical Exam. Alternatively, you can use time-based coding if you document your time and the four documentation requirements, above. There is no difference between a new or established patient for outpatient consultation codes.

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