Resilient MBS Logo
preoperation clerance icd 10 codes - resilient medical billing

Understanding Pre-Op Clearance ICD-10 Codes

In healthcare, “medical clearance” goes beyond employment or fitness papers. It also includes “pre-operative clearance” or “surgical clearance.” Preoperative clearance, including  Pre-op clearance ICD-10 classification, is a doctor’s acceptance of a patient’s medical fitness for surgery, though it’s debatable.

What Is Pre-Op Clearance?

Pre-op clearance evaluates a patient’s health before surgery. Pre-op clearance ensures the patient is healthy enough for surgery. A primary care physician, internist, or anesthesiologist usually does this evaluation.

The doctor evaluates the patient’s medical history, performs a physical exam, and orders additional tests or consultations during pre-op clearance. This evaluation detects pre-existing medical disorders like heart disease, diabetes, and breathing issues that could increase surgery complications.

Purpose Of Preoperative Clearance

As for the purpose of preoperative reviews, there have been preceding controversies among healthcare specialists. Although clearance is recognized for its underlying concept of granting surgical go-ahead, it is sometimes taken to mean that the go-ahead is a formal approval for surgery in the true and proper sense.

Proceduralist Dr. George Marzouka argues that his title as “clearance” does not reflect at all the nature and value of his recommendation, that it is not a meaningful shade of information for the surgeon. According to him, the role of preoperative evaluation mainly involves detecting the patient’s present health conditions and determining how they might result in the risk of the given surgery.

During surgery, for instance, you can unexpectedly get into a situation which is not accounted for by the plan. So clearance should rather be done in the form of a detailed assessment rather than just a health clearance for surgery. 

Nevertheless, as a progress report, the goal of the preoperative clearance is to contribute to the medical history and treatment documentation of healthcare organizations to see patient’s diagnosis and management. That is very important for precise entry of the data and of the billing, properly.

Pre-Op Clearance ICD-10 Codes

Pre Operative Clearance refers to evaluating and improving a patient’s health condition before undergoing the surgery. The coding of the correct Pre-op clearance ICD-10 codes is the requisite part of the medical billing and documentation process. 

Below are the commonly used Pre-Op Clearance ICD-10 Codes:


Encounter for preprocedural cardiovascular examination: This algorithm is applied when a cardiovascular examination is performed for a preoperative assessment or for a pre-operative procedure.


Encounter for other preprocedural examinations: In this class, the students are also exposed to various other types of preprocedural examinations.


Encounter for other specified special examinations: This code stands for special examinations under defined code of narrow medically based health problems which are not elsewhere classified.

The only way that the CPT codes work is to act as indicators of medical clearance, that is why they are there.

Which Pre-op Clearance ICD-10 codes are proper for billing?

The following  Pre-op clearance ICD-10-CM codes are billable: Z01.810 – Yes, billable: Due to inaccurate coding, the performed cardiovascular examination for the patient before procedure will be reimbursed Z01.818 – Yes, billable: Contact with other preprocedural examinations done for the diagnosis may also be billed appropriately when documented correctly ‍ Z01.89 – Yes, billable: My regimen which incorporates Pre Op Clearance, Other Specified Examinations and Encounter for Other Specified Special Examinations is also reimbursable.

What are CPT Codes?

Current Procedural Terminology (CPT) codes is a set of medical bills codes which doctors, surgeons or diagnostic services providers use to encode the procedures which they take in render. 

These codes permit them to bill providers, and the insurance companies, at the end of the month. Also, they ensure that accurate and effective communication between the providers and insurance companies is done.

ICD Codes in Medical Clearance

CPT (current procedural terminology) codes are pivotal in this context, because they draw the line between what exactly was done during the clearance visit to the clinic.

Human beings often make mistakes and a coder sometimes also does this; if such a mistake is made in coding, the doctor will not be paid adequately for his or her work and healthcare providers will no longer know what kind of services patients need.

Med clearances’ CPT codes examples


This is for an office or other kind of outpatient visit consisting of the evaluation and management of a new patient, hence requiring a detailed history, physical examination, and medical decision making.


This code describes an office visit or other outpatient visit for the evaluation and management of an established patient who requires a Comprehensive history, examination and medical decision-making.


 Electrocardiogram Routine study, at least 12 leads ECG with an interpretation and result document.

How to use I-CD10 and CPT Codes?

use of icd-10 and cpt cpt codes - resilient medical billing

The Pre-op clearance ICD-10 and CPT codes are important and must be used correctly in order to ensure Accurate billing and documentation in the medical field.

Here are some guidelines:

Coding Guidelines

  • choose the ICD-10 and CPT codes that are most suitable based on the patient’s conditions and the services rendered.
  • Keep to any relevant coding specifications offered by insurance companies or entities in control.
  • Make sure to study frequently, in order to be updated on the recent changes of ICD-10 and CPT codes for accuracy.
  • Use tabulation tools or programs to point in the right directions in terms of proper code selection.

Avoiding Common Coding Errors

  • Re-check payments and procedures before sending claims if you want to prevent claims from getting rejected or denied.
  • Perform a review of the documentation to check if codes are the true provider of the services provided.

Final Thoughts

Getting completed pre-op processes, including Pre-op clearance ICD-10, regarding either the papers or the operations, is a must to make the operation successful. For the patient to recover without complications as well.

Also, taking precise medical history does not only make sense but really mediates quality health care. While the health care providers should render appropriate medical care for their patients, an accurate and updated billing system is a must to ensure smooth medical operations.

We understand that patients stay with a clinic because of the physician’s team’s care and medical billing convenience. Resilient provides complete medical coding services to ensure your health care is in order. For further more information please email or call us. 

Leave a Comment

Your email address will not be published. Required fields are marked *