Are your surgical clearance claims being denied even when the visit was properly documented? Many claims tied to surgical clearance ICD-10 codes fail because the diagnosis code does not accurately reflect the actual purpose of the encounter. In 2026, the ICD-10-CM code set applies to dates of service on or after October 1, 2025, with additional tabular and index revisions effective April 1, 2026. These updates introduced hundreds of new diagnosis codes, increasing payer scrutiny on preoperative evaluations.
Surgical clearance exams are frequently coded incorrectly when the visit is treated as a routine exam rather than a medically necessary preprocedural evaluation. Incorrect code selection can delay reimbursement, trigger audits, or result in outright denials. In FY 2026, payers are closely reviewing documentation, diagnosis sequencing, and whether the clearance visit is separate from the global surgical package.
This guide explains how surgical clearance ICD 10 coding works in 2026. It breaks down correct code usage, documentation requirements, and payer rules that affect providers, coders, billers, and compliance teams. The goal is to help practices reduce denials and support accurate reimbursement.
Surgical Clearance ICD 10 Codes Explained
This section explains how surgical clearance is defined for clinical care and billing.
It also clarifies which ICD 10 codes apply and why incorrect use leads to denials.
What Surgical Clearance Means in Clinical and Billing Terms
Surgical clearance is a medical evaluation performed to determine whether a patient is suitable for a planned procedure. Clinically, it focuses on risk factors that may affect anesthesia, recovery, or surgical outcomes.
From a billing standpoint, surgical clearance is not a routine exam. The visit must be medically necessary, requested by another provider, and limited to a specific risk assessment. If the evaluation is unrelated to an active medical condition, coverage may be limited or denied. Timing matters. Clearance performed after the decision for surgery may fall under the global surgical package.
ICD 10 Code for Surgical Clearance
There is no single diagnosis labeled as “surgical clearance.” Instead, ICD 10 uses preprocedural examination codes to describe the encounter. These codes report the purpose of the visit, not the surgery itself.
The diagnosis must explain why the examination occurred. Supporting conditions that raise surgical risk should be disclosed individually when documented. Failure to link the exam to a valid purpose remains a common cause for payer rejection.
2026 Coding Updates That Affect Surgical Clearance
The 2026 ICD-10 updates include important changes that directly impact surgical clearance coding. Staying current ensures accurate claims, reduces denials, and supports compliance with CMS and commercial payer requirements.
Key 2026 Updates:
- No new codes added for preoperative clearance: The primary Z01.81 subcategory codes remain unchanged for 2026, including Z01.810 (cardiovascular), Z01.811 (respiratory), Z01.812 (laboratory), and Z01.818 (other preprocedural exams).
- Clarified documentation requirements: Coders must provide detailed notes for each pre-op evaluation, especially when using Z01.818, to justify medical necessity.
- POA (Present on Admission) exemption maintained: Z01.81 codes remain POA exempt, meaning they do not affect inpatient quality measures.
- ICD-9 crosswalk: The updated crosswalk remains the same; for example, Z01.810 maps to V72.81, Z01.811 to V72.82, and Z01.818 to V72.83.
- Audit and payer emphasis: Insurers are increasingly auditing preoperative clearance claims. Proper code selection and complete documentation are critical to avoid denials.
- Telehealth considerations: Pre-op evaluations conducted via telehealth are reportable with the same ICD-10 codes if documented correctly and linked to surgical preparation.
Implications for 2026:
1. Revenue cycle teams should review all Z01.81 claims for documentation accuracy.
2. Coders should avoid overusing Z01.818 without supporting evidence.
3. Providers must clearly link evaluations to the upcoming surgery and note any relevant comorbidities.
ICD 10 Preoperative Clearance Code Categories
The most commonly used diagnosis codes include:
| ICD-10 Code | Description | ICD-9 Equivalent | Use Case / Notes |
|---|---|---|---|
| Z01.810 | Encounter for preprocedural cardiovascular examination | V72.81 | Use for patients undergoing heart-focused pre-op assessment. Include comorbidities if documented. |
| Z01.811 | Encounter for preprocedural respiratory examination | V72.82 | Applies to patients with lung disease or procedures affecting breathing. Report supporting conditions separately. |
| Z01.812 | Encounter for preprocedural laboratory examination | V72.63 | Covers pre-op lab tests like CBC, CMP, and urinalysis. Must be linked to surgical planning. |
| Z01.818 | Encounter for other preprocedural examination | V72.83 | For general pre-op evaluations not fitting other categories. Avoid default use; document exam scope clearly. |
| Z01.82 | Encounter for allergy testing | V72.7 | Only for pre-op allergy evaluation affecting surgical safety. Include results in the chart. |
| Z01.83 | Encounter for blood typing | V72.86 | Pre-op blood type testing. Document purpose (transfusion, surgery prep). |
| Z01.84 | Encounter for antibody response testing | V72.61 | Used when pre-op antibody screening is performed. Link to surgery if medically necessary. |
| Z01.85 | Encounter for other specified special examinations | V72.85 | Rare pre-op exams outside other categories. Document reason, request source, and relevance to surgery. |
ICD 10 Preoperative Clearance Documentation Rules
Accurate documentation is essential for surgical clearance ICD 10 coding. Proper records ensure compliance, reduce claim denials, and support the medical and billing teams. Understanding the rules allows coders, billers, and providers to apply the correct codes while demonstrating medical necessity.
Medical Necessity Requirements
Medical necessity is the cornerstone for reporting the ICD-10 code for surgical clearance. Insurers require clear justification for preoperative evaluations, particularly when using Z01.81 subcategory codes.
Key requirements include:
1. Link to upcoming surgery: Documentation must show that the evaluation is directly related to preparing the patient for a scheduled procedure.
2. Assessment of patient health: Include a comprehensive review of medical history, comorbidities, medications, and risk factors that could affect surgical outcomes.
3. Detailed physical examination: Record focused exams based on the patient’s conditions, such as cardiovascular, respiratory, or laboratory assessments.
4. Supporting diagnostics: Include lab results, imaging studies, or other tests that support the necessity of the pre-op clearance.
5. Provider rationale: Notes should indicate why each evaluation is required for safe surgical preparation.
Implications for billing and coding:
- Claims without documented medical necessity may be denied or delayed.
- Z01.818 (other preprocedural exams) requires explicit notes for justification.
- Multiple pre-op evaluations can be coded separately if each is medically necessary and well-documented.
- Revenue cycle teams should review charts regularly to ensure all elements meet payer requirements.
Conclusion
Proper use of surgical clearance ICD 10 codes ensures accurate documentation, supports medical necessity, and protects practices from claim denials. Providers, coders, and billing teams must link each evaluation to the upcoming surgery and document supporting conditions clearly. Following these rules reduces audit risks and improves reimbursement accuracy.
Compliance requires staying current with 2026 ICD-10 updates, which include Z01.81 subcategory requirements and POA exemptions. Preoperative evaluations are reported thanks to detailed notes, precise code selection, and coordination between medical and billing staff. This approach strengthens revenue cycle management and quality patient care.
FAQs
What is the ICD 10 code for surgical clearance?
The primary ICD 10 code is Z01.81, covering preprocedural evaluations like cardiovascular, respiratory, lab, or general exams. Use specific subcodes for detailed documentation.
How do I code preoperative clearance correctly?
Select the code matching the evaluation type, link it to the planned surgery, and include supporting diagnostics and comorbidities for medical necessity.
Can Z01.818 be used for all surgical clearance exams?
No. Z01.818 is for other preprocedural exams not covered by specific codes. Document exam scope clearly to avoid claim denials.
Are telehealth preoperative evaluations reportable?
Yes. Telehealth pre-op assessments are reportable with the same ICD-10 codes if documentation links the visit to surgical preparation.
What happens if medical necessity isn’t documented?
Claims may be denied or delayed. Complete notes demonstrating the purpose of the evaluation are required for Z01.81 subcategory claims.
