2025 ICD-10-CM code Z01.81
Encounter for preprocedural examinations, including preoperative and radiological/imaging examinations.
Medical necessity for Z01.81 is established by the need to evaluate a patient's health status prior to a planned medical or surgical procedure to minimize risks and ensure the patient's safety and well-being during and after the procedure. The specific requirements for preprocedural examinations may vary depending on the patient's health condition, the complexity of the planned procedure, and payer policies.
The physician is responsible for evaluating the patient's overall health, reviewing relevant medical history, conducting a physical examination, and ordering/reviewing necessary tests (e.g., blood work, imaging) to assess the patient's readiness for the planned procedure. They must document findings, address any identified risk factors, and communicate with the procedural team.
- Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
- Z00-Z13 Persons encountering health services for examinations
In simple words: This code indicates a visit to a healthcare provider specifically for check-up and necessary tests before a medical procedure.
This code is used for encounters specifically for preprocedural examinations, which include preoperative evaluations and radiological or imaging examinations conducted as part of the preprocedural assessment.It encompasses the evaluation of a patient's health status before a planned procedure to determine their suitability and identify any potential risks.
Example 1: A patient with a history of heart disease is scheduled for a knee replacement surgery. They are seen by their primary care physician for a preprocedural examination to assess their cardiac risk and optimize their condition prior to surgery., A patient is scheduled for a colonoscopy and undergoes a preprocedural consultation and examination, which may include a review of their medical history, a physical exam, and ordering blood work to check for any potential complications., Before a planned biopsy, a patient is seen by a specialist for a preprocedural review that includes imaging studies (e.g., CT scan, MRI) to guide the procedure and assess potential risks.
Documentation for Z01.81 should include the reason for the preprocedural examination, relevant medical history, findings from the physical examination, results of any diagnostic tests performed, assessment of the patient's risk factors related to the planned procedure, and any recommendations or interventions made to optimize the patient's condition before the procedure.
** Excludes1: examinations related to pregnancy and reproduction (Z30-Z36, Z39.-)Excludes2: screening examinations (Z11-Z13)
- Payment Status: Active
- Specialties:Internal Medicine, Family Medicine, Cardiology, General Surgery, and various surgical specialties
- Place of Service:Office, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Independent Clinic