Pre-operative Consultation CPT 99241, 99275 - v72.81 , 336.13

Pre-operative Consultation

The appropriate consultation code (99241-99275) may be reported for a preoperative consultation performed by any provider, to include a patient’s primary care provider, at the request of a surgeon, as long as all the consultation requirements are met and the service is medically necessary. 

In reporting the diagnosis, it is important to remember that the role of each code is to explain why a service was provided.  In reporting “preoperative clearance” the first diagnosis code used would be the code for preoperative examination (e.g., V72.81 throughV72.84).  Additional ICD-9 codes for the condition(s) that prompted surgery and for conditions that prompted the preoperative medical evaluation should also be documented and reported.  This underlying condition determines the medical necessity for the “preoperative clearance.”  Other diagnoses and conditions affecting the patient may also be documented and reported if appropriate.

Example:
V72.81        Pre-operative cardiovascular examination
336.13        Anterior subcapsular polar senile cataract – Reason for the patient’s surgery
401.1        Essential hypertension benign – Underlying condition – why medical clearance was needed.