# Pre-op Exam



## maine4me (Mar 6, 2012)

One of our family practice doctors saw a patient for a pre-op exam prior to a dental procedure.  When I review the note I do not see any request from the dentist and or underlying conditions which would require a pre-op exam, unless the patient's mental retardation would warrant the exam.

The doctor coded the visit as follows:
99242      V72.84, 521.00
90471      V04.81
90656      V04.81

If there is no request for the pre-op exam then I have coded this visit as 99213.  But I am stumped on the diagnosis for the E/M.  The flu shot and administration are coded correctly.  

I could you some advice.  The note is below.

Assessment and Plan
Ambulatory Assessment/Plan:  
Assessment/Plan:
V72.84 Pre Operative Physical Exam

Additional Plan Details:
Preop for dental procedure/cleaning - well 24 y/o female with MR.  No changes to health hx.  Normal baseline per parents.  Depo for dysmenorrhea, otherwise no meds.  Flu shot today.  F/u with PCP for routine health issues/labs.  F/u sooner prn.

HPI
HPI
Nursing Chief Complaint:  Pre-op clearance - dental procedure - flu shot

Physician:  24 y/o female presents with parents for pre-op PE for dental check-up scheduled 11/15/11.  Wisdom teeth pulled last year.  No concerns.  Parents deny changes to PMHx.  ROS as per PE forms.  No CP/SOB, no ST, cough.  No behavior changes, no changes in po intake.  No f/c.  No rashes.
Vitals:  
     Height 62 in / 157.48 cm
     Weight 224 lbs  / 101.604698 kg
     BSA 2.16 m2
     BMI 41.0 kg/m2
     Temperature 98.1 F / 36.72 C - Tympanic
     Pulse 120
     Blood Pressure 120/82, Right Arm
Personal Medical History
Personal medical history:  Hx of: High cholesterol, Obesity, Mental Retardation, Other - MR with global developmental delay (unkown etiology)

Surgical History
Past Surgical History:  Hx of: Other - teeth work - had general anesthesia, had eye surgery

Family History
Family history of CV disease:  Positive:: FH coronary artery dis.

Social History
Social history:  
   Marital Status:  Single
   Household members:  lives home with mom, dad, brother
   Occupation:  attends day program

Alcohol
Alcohol Intake:  None

Substance Use
Substance use:  Denies use

Problem List
-----

	Past Medical/Surgical History
	Chronic Problems:
	MENTAL RETARDATION NOS
	OBESITY, NOS
	PURE HYPERCHOLESTEROLEM

EXAM
*****
*****
General:  No acute distress.  Pleasant, interactive, minimally verbal.  HR recheck 90, RR 14.

HEENT:  Sclera nonicteric, TM normal bilaterally, pharynx clear without exudate. 

Neck:  Supple, no lymphadenopathy.  FROM.

Lungs:  Clear to auscultation bilaterally. 

Heart:  Regular rate and rhythm without murmurs or rubs.

Abd: obese, soft, normal BS, no TTP.

Neuro: grossly intact.

Ext: FROM x 4 ext, strength 5/5.  PPP, no c/c/e.

Skin: warm, dry, no lesions/rashes


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## Jenr0406 (Mar 25, 2016)

*CPT for preop clearance by PCP*

Now that we are in 2016 I am hoping there is a better way to code a encounter w/ a PCP for a pre-procedural exam. There are no complaints that the pcp is treating. The surgery is for dislocated discs in neck. Diagnoses used is Z01818. What CPT should I be reviewing?


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