Wiki Coding Pre OP EKG

[kbarron]

I have a coding issue with this. I have always been under the impression the dx for surgery goes first followed by pre op cardiovascular exam. We have a patient that was coded as V72.81 V72.83 728.6. I thought is was not advisable to use two codes from the same "family" of codes. E&M giude from CMS states the "Conditions prompting the surgery must be on the claim, it does not state where.

 

[dclark7]

If you read the coding guidelines at the beginning of your ICD book they state in
Section IV (Diagnosis Coding and Reporting Guidelines For Outpatient Services) Subsection N - Patients receiving preoperative evaluation only. "For patients receiving preoperative evaluation only, sequence first a code from category V71.8x, (Other specified examinations), to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.

So to answer your question, according to ICD coding guidelines you only need one code from the V72.8x "family" and then the code for the surgery and then any additional dx codes. Hope this hleps.