For instance, a surgeon looks to the internist for preoperative clearance to perform a hip replacement. The patient has known heart disease and emphysema, the internist would use V72.81 to indicate that the reason for the visit is a pre-operative cardiovascular exam. And, code also the reason for the surgery, example, degenerative hip disease. The other diagnosis would identify the coronary artery disease (ex, 414.01), and the emphysema ex, (492.8).
The appropriate ICD-9 (Diagnosis) code for pre-operative examination (e.g.,
V72.81 is primary code, followed by the appropriate ICD-9 (Diagnosis) code for the medical condition(s) prompting the need for the service to be performed pre-operatively (CAD and emphysema), and, the appropriate ICD-9 (Diagnosis) code for the condition(s) that prompted the decision for surgery (degenerative hip disease). The appropriate E/M code (99201-99215), to describe level and status, (new or established patient).
on the history, physical and medical decision making (actually on 2 of those 3). A patient with one medical problem is probably going to be 99213, 3 or more problems is 99214. A real sickie would be 99215