Make sure pre-op visit documentation shows medical need to be cleared

Why This Topic Matters

Pre-operative clearance visits can create audit and repayment risk when the service is not medically necessary or is not well documented. Understanding the payer perspective and how to connect the visit to underlying conditions helps practices support claims appropriately and reduce denials.

Article Sections

1. Patient encounters

   Introduces the topic by discussing when a separate pre-operative clearance visit may or may not be warranted and how payer expectations can differ.

2. Dos and don’ts of pre-operative clearance

   Outlines broad documentation and billing considerations for pre-operative clearance visits, including medical necessity, chief complaint alignment, diagnosis selection, and coordination with the surgeon.