For a routine clearance or because of a problem?
Routine I would use either a preventive code, if they have no issues, or the correct new/established code if they do have issues but it is still just routine.
If this is a non-medicare patient and they surgeon is actually waiting for the PCPs opinion on whether or not the patient is ok to have surgery I would use a consult code. If it is a medicare patient, you have to to go with the correct new/established code.
Laura, CPC, CPMA, CEMC
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