Pre-pocedure clearance


Craig, CO
Best answers
We generally perform open access endoscopy (no visit required if patient referred specifically for endoscopy). However, sometimes patients have a condition that warrants a pre-procedure office visit. We have differing opinions as to the correct diagnosis codes to use in this scenario. Should we use the V-codes for pre-op clearance or the code for the actual problem that prompted the visit, i.e. COPD, cardiac issues, etc. I would appreciate any input! Thanks.

Tina Smith, CPC, CPC-H, CGCS
Pre op Clearance

For pre op clearance I use the medical complications, then the reason for the surgery, then the v code. Hope this helps.
This would depend (the Dx coding sequence) on the payer to some extent.

ICD tells you to list first the reason for the visit (in this case, Pre-surg clearance), a V-code. Next, sequence the condition "describ[ing] the reason for the surgery [procedure] as an additional diagnosis. Code also any finding related to the . . . evaluation."

I know some payers have demands/expectations for a different sequence; I would request those from the payer source in writing and code accordingly. However, because the visit is primarily for surgical clearance, if payers had no specific guidance, I would follow the rules stated in ICD.

Good luck.