What is the ICD-10 code for pre-op cardiac clearance?

Z01.810, Encounter for preprocedural cardiovascular examination, is sequenced first. Add the condition that is the reason for the surgery and any findings from the evaluation.

Is the surgical diagnosis first-listed on a pre-op visit?

No. For a preoperative evaluation only, a Z01.81- code is first. The condition requiring surgery is reported as an additional diagnosis.

Should I use Z01.818 or Z01.810 for a pre-op clearance?

Use Z01.810 when the provider documents a cardiovascular examination before the procedure. Use Z01.818 for a preprocedural examination that is not cardiovascular, respiratory, or laboratory, including one documented only as a preoperative examination.

Should chronic conditions be coded on a clearance visit?

Code any findings related to the pre-op evaluation. A chronic condition the provider assessed to determine surgical risk is part of that evaluation.

ICD-10-CM guide

ICD-10 Codes for Pre-Op Clearance: How to Use Z01.81-

How to code a preoperative evaluation: Z01.81- first, the reason for the surgery next, then any findings and conditions that affected the clearance.

Reviewed 2026-10-20 | 2 min read

A pre-op clearance visit is one of the few outpatient encounters where the first-listed code is not the patient's main medical problem. The patient came in so the provider could decide whether a planned procedure is safe. ICD-10-CM gives that purpose its own subcategory, Z01.81-, and the guidelines spell out the order for everything that follows it.

Sequence the pre-procedural exam first

For a patient receiving a preoperative evaluation only, the guidelines direct you to sequence first a code from Z01.81-, Encounter for pre-procedural examinations. Next, assign a code for the condition that is the reason for the surgery. Then code any findings related to the pre-op evaluation.

Pick the Z01.81- code that matches the exam

Use the code that matches the examination the provider documented. A documented cardiovascular evaluation is Z01.810, while a preoperative examination documented without naming a system falls to Z01.818, the code that includes preprocedural examination NOS.

Z01.810, Encounter for preprocedural cardiovascular examination.
Z01.811, Encounter for preprocedural respiratory examination.
Z01.812, Encounter for preprocedural laboratory examination.
Z01.818, Encounter for other preprocedural examination.

The reason for surgery is a secondary code

The planned procedure has a diagnosis behind it, such as knee osteoarthritis before a replacement. That diagnosis is reported as an additional code, coded to the specificity the record supports, including laterality. It explains why the clearance was needed, but it is not what the encounter was chiefly for.

Add the findings that shaped the clearance

Code also any findings related to the pre-op evaluation. A chronic condition such as hypertension that the provider evaluated to judge surgical risk belongs on the claim. So does a new finding discovered during the evaluation.

When the pre-op codes do not apply

Pre-operative examination and pre-procedural laboratory Z codes are for situations where the patient is being cleared for a procedure and no treatment is given. If the visit turns into treatment of a condition, code the condition that was treated rather than presenting the visit as a clearance.

A clearance visit is also different from the day of surgery. When the patient presents for outpatient same-day surgery, the reason for the surgery is the first-listed diagnosis, even if the surgery is not performed because of a contraindication.

Questions coders ask

What is the ICD-10 code for pre-op cardiac clearance?: Z01.810, Encounter for preprocedural cardiovascular examination, is sequenced first. Add the condition that is the reason for the surgery and any findings from the evaluation.
Is the surgical diagnosis first-listed on a pre-op visit?: No. For a preoperative evaluation only, a Z01.81- code is first. The condition requiring surgery is reported as an additional diagnosis.
Should I use Z01.818 or Z01.810 for a pre-op clearance?: Use Z01.810 when the provider documents a cardiovascular examination before the procedure. Use Z01.818 for a preprocedural examination that is not cardiovascular, respiratory, or laboratory, including one documented only as a preoperative examination.
Should chronic conditions be coded on a clearance visit?: Code any findings related to the pre-op evaluation. A chronic condition the provider assessed to determine surgical risk is part of that evaluation.

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Sources

ICD-10-CM Official Guidelines for Coding and Reporting FY 2027
Section IV.M, Patients receiving preoperative evaluations only
ICD-10-CM Official Guidelines for Coding and Reporting FY 2027
Section I.C.21.c.12, Routine and Administrative Examinations
ICD-10-CM Official Guidelines for Coding and Reporting FY 2027
Section IV.A.1, Outpatient Surgery
FY 2027 ICD-10-CM Tabular List and Alphabetic Index
Tabular List, code Z01.818
ICD-10-CM Official Guidelines for Coding and Reporting FY 2027
Section I.B.13, Laterality
FY 2027 ICD-10-CM Code Descriptions in Tabular Order
Codes Z01.810, Z01.811, Z01.812, Z01.818