Nextcare coverage of pre-operative tests is based on the ASA classification (Table 1), physical examination findings and surgery grade (minor, intermediate, and major/complex) as classified by the American Association of the Family Physician:
| ASA classification | Definition | Examples, including but not limited to |
| ASA I | A normal healthy patient | Healthy (age is taken into consideration) |
| ASA II | A patient with mild systemic disease | Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease like asthma. |
| ASA III | A patient with severe systemic _ NEdisease | Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents. |
| SA IV | A patient with severe systemic disease that is a constant threat to life | Examples include (but not limited to): recent (<3months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis |
| ASA V | A moribund patient who is not expected to survive without the operation | Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction |
(https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system).
Medically justified pre-operative tests, as per the policy terms and conditions of each health insurance plan will be approved only after approval of the in-patient procedure/surgery, if the surgery is not covered, the pre-operative tests also will not be covered. As per the published Guidelines for Preoperative testing by the American College of Cardiology (ACC) and the American Heart Association (AHA), the factors which guide decision making include the surgery specific risks, patient’s cardiovascular risk and functional capacity.(https://www.nice.org.uk/guidance/NG45)
Tests are valid for 6 months (provided there have been no interim change in the patient’s condition, if there have been changes kindly submit all the relevant the reports to justify the repetition of the tests). For patients receiving a preoperative evaluation, code first the reason for the encounter from ICD-10-CM code set Z01.810 to Z01.818:
Assign a code for the condition to describe the reason for the surgery as an additional diagnosis to prevent any delays in the approval and to avoid pending of the claim. Example, a patient presents for a preoperative examination for carpal tunnel surgery on the right wrist and has orders from his surgeon for laboratory tests. You would assign diagnosis code Z01.812, as already noted, for the primary diagnosis, and G56.01, “Carpal tunnel syndrome, right upper limb” as the additional diagnosis. Findings related to the preoperative evaluation must be code as well. Basic covered pre-operative tests are:
| CPT Description | |
| 85025 | Blood count; complete (CBC) |
| 85610 | Prothrombin time |
| 85732 | Thromboplastin time, partial (PTT) |
| 86703 | Antibody; HIV-1 and HIV-2 |
| 86803 | Hepatitis C antibody |
| 87340 | Hepatitis B |
(https://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-adult-healthy-patient)
Additional pre-operative tests that can be approved according to the member’s comorbidities are listed below:
| CPT | Description |
| 93306 | ECG |
| 80069 | Kidney function test |
| 94010 | Lung function tests |
The below tests are covered for maternity pre-operative procedure if not approved in antenatal care:
| CPT Description | |
| 86900 | Blood typing; ABO |
| 86901 | Blood typing; Rh (D) |
| 86850 | Antibody screen, RBC, each serum technique |
Low risk procedures/surgeries:
For low risk procedures/surgeries, Preoperative tests are not covered, until and unless medically indicated. Some examples of low risk procedures/surgeries (but not limited to) are below:
References
