What CPT codes are used for pre-operative clearance?

Use standard E/M codes 99202-99215 based on MDM complexity. Pre-op evaluation for patient with multiple comorbidities typically supports 99214-99215. Medicare eliminated consultation codes; commercial payers may accept 99241-99245. Document the surgical procedure, anesthesia type, and cardiovascular risk assessment to support code level.

What cardiovascular risk assessment documentation is required?

Document: surgical risk category (low 5%), functional capacity in METs (≥4 METs adequate), active cardiac conditions (unstable angina, decompensated HF, significant arrhythmia, severe valve disease), and clinical risk factors (RCRI score). Use ACC/AHA guidelines for systematic assessment. Document whether further cardiac testing is needed.

How should perioperative medication management be documented?

Document: which medications to continue (beta-blockers, statins), which to hold (anticoagulants with specific timing, ACE/ARBs, metformin, oral hypoglycemics), and bridging plans if needed. Include specific timing for holding and resuming medications. For anticoagulation, document indication, bridging decision rationale, and communication with surgeon/anesthesia.

What documentation supports clearance decisions?

Document: clear statement of clearance status (cleared, cleared with conditions, not cleared), specific recommendations for optimization, conditions that must be met before surgery, and any additional testing required. If not clearing, document specific reasons and what would be needed for clearance. Copy surgeon on clearance letter.

When is additional cardiac testing needed before surgery?

Document indication for additional testing: poor functional capacity (<4 METs) with clinical risk factors undergoing elevated-risk surgery, active cardiac symptoms, or new concerning findings. Document when testing is NOT needed (low-risk surgery, adequate functional capacity, no symptoms). Avoid unnecessary testing that delays appropriate surgery.

Pre-operative Clearance Template - Surgical Clearance

Primary Care — Pre-operative Clearance Template

Primary Care Internal Medicine Updated: 11/7/2025

The Pre-operative Clearance Template is designed for primary care providers and internists conducting medical clearance evaluations for patients scheduled for surgery. This template documents the comprehensive assessment required to determine surgical risk and optimize patients for procedures including cardiovascular risk assessment, medication management, optimization of chronic conditions, and clearance recommendations. The template supports appropriate billing for pre-operative consultations (CPT 99241-99245) and includes sections for planned surgery and surgeon information, patient's medical history and chronic conditions, current medications requiring perioperative management, cardiovascular risk assessment, functional capacity evaluation, physical examination findings, laboratory and diagnostic test results, risk stratification, recommendations for perioperative management, and clearance determination. This template ensures thorough pre-operative evaluation, identifies modifiable risk factors, supports appropriate surgical planning, and protects both patients and providers through comprehensive documentation. Ideal for primary care practices, internal medicine practices, and practices providing pre-operative clearance services.

Visit Information

Planned surgery: [Procedure name]
Surgeon: [Surgeon name]
Scheduled date: [Date]
Surgery type: Elective / Urgent / Emergent
Anesthesia type: [General / Regional / Local]

Medical History

Active medical conditions: [List all conditions]
Past medical history: [Relevant history]
Past surgical history: [Previous surgeries and complications]
Current medications: [List all with dosages]
Allergies: [List]
Family history: [Relevant family history]

Cardiovascular Risk Assessment

Cardiac symptoms: None / Chest pain / Dyspnea / Palpitations / Syncope
Functional capacity: [METs or activity level]
Cardiac risk factors: [Hypertension, diabetes, smoking, etc.]
Previous cardiac evaluation: [If applicable]

Physical Examination

Vital signs: BP, HR, RR, Temp, SpO2, BMI
General: Appearance
Cardiovascular: Heart rate, rhythm, murmurs, JVD, peripheral pulses, edema
Pulmonary: Clear to auscultation, no wheezes
Abdominal: [If relevant]
Other: [Relevant findings]

Laboratory/Diagnostic Tests

ECG: [Results if obtained]
Chest X-ray: [Results if obtained]
Labs: [CBC, CMP, coagulation studies, etc.]
Other: [Echocardiogram, stress test, etc. if obtained]

Assessment

1) Pre-operative evaluation for [surgery type]

Surgical risk: Low / Moderate / High
Cardiac risk: Low / Moderate / High
Pulmonary risk: Low / Moderate / High
Other risk factors: [Specify]

2) [Active medical conditions and optimization status]

Plan

1) Clearance: Cleared for surgery / Cleared with recommendations / Not cleared: [reason]
2) Perioperative management:

Medications: Continue / Hold / Adjust: [specify]
Anticoagulation: [Management plan]
Blood pressure: [Management plan]
Diabetes: [Management plan]
Other: [Specify]

3) Recommendations: [Pre-operative optimization, further evaluation if needed]
4) Follow-up: [If needed]

Provider Communication

Surgeon notified: Yes / No
Anesthesia notified: Yes / No
Recommendations communicated: [How communicated]

Primary Care — Pre-operative Clearance Template

Template