Pre-Op Clearance ICD-10 Codes: How to Ensure Optimal Patient Care

Are your pre-operative clearance claims getting denied despite providing thorough patient evaluations? You’re not alone. Medical practices across the country lose thousands in revenue annually due to improper pre-op clearance ICD-10 coding. According to the Centers for Medicare & Medicaid Services (CMS), proper documentation of these exams is key to reimbursement. It’s about protecting your bottom line while ensuring patients get timely surgical care.

This guide walks you through everything you need to know about pre-surgery testing ICD-10 and preoperative exam ICD-10 codes, and shows how modern RCM solutions can eliminate these headaches.

What Are Pre-op Clearance ICD-10 Codes?

Before any patient goes for surgery, healthcare providers need to ensure they’re medically fit for surgery. These codes communicate to payers that a patient requires medical evaluation before a surgical procedure to assess surgical risk and optimize outcomes. This involves reviewing medical history, conducting physical examinations, and ordering necessary tests like blood work, EKGs, or imaging studies.

The 2026 edition of ICD-10-CM codes, effective on October 1, 2025, keeps these Z01 subcodes in use, so it is important for medical billers and coders to stay current with the latest coding updates.
From a billing perspective, accurate pre-op clearance ICD-10 coding is essential because:

• Documents medical necessity
• Secure correct reimbursement
• Supports communication between providers and payers
• Helps maintain compliance with coding standards

Understanding the Z01.81 Code Family

Preoperative clearance codes fall under the Z01 category for “Encounter for other special examination without complaint, suspected or reported diagnosis.” These codes communicate to payers that a patient requires medical evaluation before a surgical procedure to assess surgical risk and optimize outcomes. The most commonly misunderstood codes include:

• Z01.810: Encounter for preprocedural cardiovascular examination.
• Z01.811: Encounter for preprocedural respiratory examination.
• Z01.812: Encounter for preprocedural laboratory examination.
• Z01.818: Encounter for other preprocedural examination.

Why this matters:

Using the correct Z-code helps justify medical necessity, ensures the visit is understood as a clearance encounter, and reduces the risk of denials. According to AAFP coding guidance, the Z01 code should be sequenced before the surgical diagnosis

Complete Code Reference Table for You

Why these Matter:

• Z01.810-Z01.818 are billable codes
• Avoiding the non-specific Z01.81 parent code
• These Z-codes must be sequenced first for pure pre-op evaluation visits.

Note: The legacy ICD-10 V72.84 was replaced by Z01.818 in October 2015, yet 12% of practices still use the obsolete code, causing automatic denials.

How to Properly Code for a Pre-Op Examination to Ensure Patient Care

1. Testing vs. Full Pre-Op Exam:

• Use Z01.812 when the encounter is lab-only (tests ordered but no physical exam)
• Use Z01.818 if a full pre-op evaluation is done (history, physical and possibly testing)
• According to coding best practices, you should clearly document each part (test, exam, plan) to justify the encounter’s complexity.

Note: Pre-Op Clearance visits are critical for ensuring patient safety before surgery and are typically documented using specific ICD‑10 codes, such as Z01.818. For coding and billing guidance, resources like the Hello MDs blogs on CPT 99396 (preventive medicine) and E/M visits (99202, 99205) provide detailed insights on how to correctly code preoperative evaluations and related services

2. Medical Necessity and Linkage

• For Z01.818-coded encounters, link your diagnosis to the planned surgical CPT (e.g., a specific surgery).
• Capture and document risk factors (such as cardiac conditions, diabetes, and hypertension) to support clearance necessity.
• Include the surgeon’s written request for clearance in your documentation. This strengthens medical necessity and can reduce denials.

Specialty-Specific Scenarios That Confuse Coders

Laboratory-Only Clearance:

If a patient comes in just for preoperative labs, use Z01.812 as the primary diagnosis. Pair it with the surgical diagnosis (e.g., “knee replacement”) and any comorbidities

Cardiac Clearance ICD-10

For a patient needing pacemaker evaluation before orthopedic surgery:

• Primary: Z01.810
• Secondary: I25.10 (CAD), Z95.0 (pacemaker status), if clinically relevant
• Documentation: Must include “cardiac risk stratification for anesthesia”, EKG results, functional capacity/anesthesia risk in your notes.

ICD-10 MRI Clearance

For claustrophobia patients needing sedation:

• Primary: Z01.818
• Secondary: F40.240 (claustrophobia), only if documents in the medical record
• Key: Document the physician’s request for MRI for pre-op clearance, perform a safety screen for MRI risk (e.g., metal, implants), and note any sedation plan.

Preoperative EKG ICD-10

When billing for EKG interpretation during clearance:

• Technical: 93000 (EKG) with Z01.810.
• Professional: 93010 with the same diagnosis.
• Mistake to avoid: Don’t R94.31 as the primary diagnosis when the purpose of the visit is clearance, because that misrepresents the visit.

Documentation Checklist for Clean Claims in Pre Op Exam

Based on AMA’s CPT guidelines (pdf form), every pre-op exam ICD-10 claim needs:

• Surgeon’s written request (can be electronic)
• Planned procedure identified by CPT/HCPCS
• Risk assessment specific to the procedure
• Detailed exam notes (history & physical)
• Results of labs, EKG, imaging, PFT, etc.
• Clearance decision statement
• Coordination of care, note if referrals are needed

At HelloMDs, our medical billing audit services often catch missing fields in this checklist and work with provider teams to correct documentation before submission, significantly reducing denials.

Common Coding Mistakes In Pre-Op Clearance

1. Wrong Primary Diagnosis:

• Using a surgical indication (e.g., M25.561) instead of a pre-op clearance Z-code (like Z01.810, Z01.812, Z01.818) can trigger denials or payer confusiin

2. Modifier Misuse:

• Applying -25 to a clearance visit when documentation does not support a “significant separately service” is a common error. Always assess if the encounter is truly distinct and well-documented

3. Bundling Errors:

• Combining pre-op clearance with routine visits (e.g., annual physical), without clearly separating or documenting both parts, can lead to incorrect billing or denials.

4. Outdated Codes:

• Using ICD 9 V72.84 (not valid under ICD 10) is risky.
• Choosing generic Z01 codes instead of the specific preprocedural codes (Z01.810, Z01.812, Z01.818) can mischaracterize the visit.
• Contrary to some beliefs, Z01.12 is not deleted in ICD-10-CM. Use the correct Z01 codes instead of inaccurate replacements.

Financial Impact of Denied Pre-Op Claims

Denied claims can cost an average of $25-$118 to rework, depending on complexity. If your practice processes 50 pre op clearance claims per month and even 10% are denied and reworked, the annual cost could range from $1,500 to $7,100, not including the impact of delayed payments or denials.

With Hello MDs’ denial management and audit solutions, you can minimize this rework burden and recover more revenue.

Conclusion:

Mastering pre-op clearance ICD-10 codes requires more than memorization. It demands integrated workflows, specialty expertise, and proactive denial prevention. The gaps competitors miss (surgeon request tracking, payer-specific rules, telehealth updates) are costing practices real money.

At HelloMDs, our RCM healthcare services transform pre-op clearance from a coding headache into a streamlined revenue stream. We reduce your denials, faster reimbursement, and minimize rework and administrative burden.

Ready to stop leaving money on the table? Partner with HelloMDs and let our certified experts handle your medical billing and coding complexities while you focus on patient care.

Disclaimer:

This content is provided for general billing and coding education only and does not substitute for professional medical, legal, or financial advice. Please verify ICD-10 codes and related guidance using official resources or a certified expert. Some images in this content are AI-generated and used solely for illustration.