Pre-pocedure clearance

tsmith

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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
 

kbarron

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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.
 

kevbshields

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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.
 
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