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Coding Z01818 for ENT

S

shelley.pence@icloud.com

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Waynesfield, OH
Question for anyone who can answer. We are having different viewpoints of if Z01818 can be used in an ENT office when the provider is making the decision that the patient needs surgery. Ex: When a pt comes into the ENT office and after exam, surgery is recommended and decided. Is there ever a time when dx code Z01818 should be used in this case? Thank you
 
What was the intent of the visit? When the patient came to the office, do you already know that they will undergo surgery? I'm guessing no. So you'd code for the condition that emerges as the reason that the surgeon is making that surgical decision. Generally a symptom or disease is reported here.

Z01.818 is used after the decision for surgery has been made and a physical exam is necessary to support medical clearance.
 
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