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Wiki E/M code for pre operative exam

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stomlinson@prairiepediatrics.com

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We are a pediatric primary care clinic. Most of our little patients require us to do a preop exam prior to any type of anesthesia, whether it be for a surgical procedure or an MRI. Prior to 2021 we usually billed this out with the preop diagnosis Z01.818 and the reason for the procedure (i.e. Seizure Disorder G40.909 or Dental Caries K02.9) with an E/M level appropriate to the detailed or comprehensive history and exam. Now with the new E/M criteria I am not sure what level to use since it no longer goes off of the history and exam, but on the diagnosis itself. I would not consider the preop diagnosis as acute or chronic and if we go by the secondary diagnosis of Seizure disorder or Dental caries I would consider those either acute or chronic, but that would be a level of 99213, which does not reflect the amount of work the provider did in establishing good health for anesthesia. What is anyone else doing?
 
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