Pre-op Evaluation

Use .fsupreopclearance in a blank note (or your speed button if you have one)

See Powerpoint (below) for Dr. Coghill's simplified Pre-Op Evaluation algorithm

Calculators

Lee Goldman's Revised Cardiac Risk Index for Pre-Operative Risk

NSQUIP Surgical Risk Calculator

Duke Activity Status Index (Functional Status Evaluation)

Bleeding Risk

Common Procedures and Associated Bleeding Risk (ACC/AHA)

HAS-BLED Score for Major Bleeding Risk

Billing

Q: What ICD-10 codes should we report for a preoperative exam?

A: The first ICD-10 code listed for a preoperative exam is typically Z01.818, “Encounter for other preprocedural examination.” List secondary codes to describe the reason for the procedure and any exam findings. However, if the exam is focused solely on the cardiovascular system (e.g., preoperative electrocardiogram), report code Z01.810. Likewise, report code Z01.811 for an exam focused on the respiratory system (e.g., pulmonary function testing). Note that you should report a preoperative chest x-ray with code Z01.818 because the chest x-ray does not focus solely on the respiratory system but also includes findings related to the heart and other structures visible on the x-ray. Report preoperative laboratory testing with code Z01.812.

Guidelines

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery