Clinical UM Guideline

 

Subject: Preoperative Testing for Low Risk Invasive Procedures and Surgeries
Guideline #: CG-MED-61 Publish Date:    12/27/2017
Status: New Last Review Date:    11/02/2017

Description

This document addresses when the following routine preoperative tests are considered clinically appropriate: CBC, WBC, PT/PTT, metabolic panel, urinalysis, chest x-rays, resting electrocardiogram (ECG), resting echocardiogram and pre-procedure consultation.  In addition to addressing when these specific tests are clinically appropriate, the criteria in this document are supported by scientific evidence, in order to identify, stratify, and reduce risk for major postoperative complications in healthy asymptomatic individuals without risk factors for systemic disease who are less than 65 years of age.  Evidence suggests that a targeted history and physical exam should determine whether pre-procedure laboratory studies should be obtained.

Note:  This document addresses routine preoperative testing for certain elective, low risk, invasive procedures and non-cardiac surgeries (see Criteria A and B below).

Clinical Indications

Medically Necessary:

Preoperative testing is considered medically necessary when ALL the following criteria are met (A, B, and C):

  1. Preoperative testing may include any, or all, of the following when done as part of a preoperative evaluation before low risk invasive procedures or non-cardiac surgeries:
    1. Comprehensive blood counts (CBC, WBC, PT/PTT, metabolic panel);
    2. Urinalysis;
    3. Chest X-rays;
    4. Resting ECG;
    5. Resting echocardiogram;
    6. Pre-procedure consultations.
      and
  2. Low risk invasive procedures and surgeries may include the following when criteria are met:
    1. Cataract surgery;
    2. Glaucoma surgery;
    3. Upper endoscopy;
    4. Colonoscopy;
    5. Cystoscopy;
    6. Arthroscopy.
      and
  3. Preoperative testing is considered medically necessary for persons 65 years of age or older or for persons less than 65 years of age with risk factors for postoperative complications or symptoms suggestive of a significant systemic disease process (ASA III or IV*) when the same tests have not been performed in the previous 30 days and when ANY of the following conditions are present:
    1. Anemia; or
    2. Bleeding disorders; or
    3. Other hematologic disorders; or
    4. Cardiovascular disease; or
    5. Pulmonary disease; or
    6. Renal disease; or
    7. Liver disease; or
    8. Endocrine disease; or
    9. Malignancy; or
    10. Hypertension; or
    11. Diabetes; or
    12. Recent upper respiratory infection; or
    13. History of smoking; or
    14. History of alcohol abuse; or
    15. History of steroid use; or
    16. History of anticoagulant therapy.

Note: 
*For definitions of American Society of Anesthesiologists (ASA) physical status classifications, see the Definitions section.

Not Medically Necessary:

Preoperative testing is considered not medically necessary when ALL of the following criteria are met:

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

99241

Office consultation for a new or established patient (problem focused history and exam, straightforward decision making)

99242

Office consultation for a new or established patient (expanded problem focused history and exam, straightforward decision making)

99243

Office consultation for a new or established patient (detailed history and exam, low complexity decision making)

99244

Office consultation for a new or established patient (comprehensive history and exam, moderate complexity decision making)

99245

Office consultation for a new or established patient (comprehensive history and exam, high complexity decision making)

93000

Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report

93005

Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report

93010

Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only

93306

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography

93307

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography

93308

Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study

85025

Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count

85027

Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)

85610

Prothrombin time

85730

Thromboplastin time, partial (PTT); plasma or whole blood

80047

Basic metabolic panel (Calcium, ionized)

80048

Basic metabolic panel (Calcium, total)

 

 

ICD-10 Diagnosis

 

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

Discussion/General Information

A series of recommendations have been formulated by multiple medical specialty societies to assess the need for performing routine tests (for example, blood counts, chest x-ray and ECG), as part of the preoperative work-up before certain invasive procedures and surgeries considered low risk for postoperative complications in healthy individuals less than 65 years of age. According to the American Society of Anesthesiologists (ASA), the following excerpts are provided for consideration regarding preoperative testing:

Performing routine laboratory tests in patients who are otherwise healthy is of little value in detecting disease. Evidence suggests that a targeted history and physical exam should determine whether pre-procedure laboratory studies should be obtained…The risk specifically related to the surgical procedure could, however, modify the preoperative recommendation to obtain laboratory studies and, when the need arises, the decision to implement should include a joint decision between the anesthesiologists and surgeons. This should be applicable to all outpatient surgery...The role of preoperative cardiac stress testing has been reduced to the identification of extremely high-risk individuals, for instance, those with significant left main disease for which preoperative revascularization would be beneficial regardless of the impending procedure. In other words, testing may be appropriate if the results would change management prior to surgery, could change the decision of the patient to undergo surgery, or change the type of procedure that the surgeon will perform (Apfelbaum, ASA, 2012).

Regarding performance of 12-lead resting electrocardiogram (ECG), the American College of Cardiology, American Heart Association (ACC/AHA) updated guideline on Perioperative Cardiovascular Evaluation and Management of Patients undergoing Non-cardiac Surgery provides the following guidance:

Preoperative resting 12-lead electrocardiogram (ECG) is reasonable for patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk surgery (Class IIa; Level of Evidence: B).

Preoperative resting 12-lead ECG may be considered for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery (Class IIb; Level of Evidence: B).

Routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures (Class III Harm; Evidence level: B). (Fleisher, 2014)

Individuals who underwent elective hernia repair (n=73,596) were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2005-2010. The NSQIP is a nationally validated, risk-adjusted, outcomes-based program sponsored by the American College of Surgeons (ACS) and designed to measure and improve the quality of surgical care. The NSQIP collects data for individuals undergoing inpatient and outpatient surgical procedures at participating institutions. In 2010, data were collected from 258 university and private sector medical centers. The NSQIP data includes 1,334,886 subjects who underwent surgery at participating institutions between 2005 and 2010. Individuals who underwent hernia repair were selected using current procedural terminology codes for open or laparoscopic inguinal hernia repair (49505, 49520, 49525, 49650, and 49651), femoral hernia repair (49550 and 49555), umbilical hernia repair (49585), and epigastric hernia repair (49570). Inclusion criteria were as follows: (1) age older than 18 years, (2) elective surgery, (3) same-day admission, (4) no surgical procedures in preceding 30 days, and (5) no additional surgical procedures at the time of the hernia repair. A total of 84,813 individuals met the inclusion criteria, but the final cohort included only 73,596 subjects after the application of exclusion criteria which included: subjects with ASA physical status class 4 or 5, cancer-related conditions and therapies, acute renal failure, impaired sensorium, ventilatory support, and sepsis, where preoperative testing was clearly indicated and ambulatory surgery was not indicated.  In addition, pregnancy and subjects with missing age, gender, or race data were excluded.

Preoperative laboratory testing was defined as any laboratory test obtained within 30 days of surgery. Laboratory tests collected in the NSQIP included hematocrit, white blood cell (WBC) count, platelet count, sodium, blood urea nitrogen (BUN), creatinine, partial thromboplastin time (PTT), prothrombin time (PT), International Normalized Ratio (INR), albumin, total bilirubin, aspartate aminotransferase (AST), and alkaline phosphatase. The majority of participants who had a hematology test (91.9%), chemistry tests (89.8%), and liver function tests (89.0%) had all tests included in the panel. A total of 46,977 (63.8%) subjects underwent testing, with at least one abnormal test recorded in 61.6% of trial participants. In trial subjects with no NSQIP comorbidities (n=25,149) and no clear indication for testing, 54% received at least one test. In addition, 15.3% of subjects underwent laboratory testing the day of the operation. In this group, surgery was done despite abnormal results in 61.6% of same day tests. In multivariate analyses, testing was associated with older age, ASA class >1, hypertension, ascites, bleeding disorders, systemic steroids, and laparoscopic procedures. Major complications (reintubation, pulmonary embolus, stroke, renal failure, coma, cardiac arrest, myocardial infarction, septic shock, bleeding, or death) occurred in 0.3% of the included subjects. After adjusting for individual and procedure characteristics, neither testing nor abnormal results were associated with postoperative complications. The authors concluded that preoperative testing is overused in individuals undergoing low-risk, ambulatory surgery, and that neither testing nor abnormal results were associated with postoperative outcomes. On the basis of high rates of testing in healthy individuals, it was noted that physician and/or facility preference, not only the individual’s condition, currently dictate use of preoperative test patterns and that involvement from surgical societies is necessary to establish guidelines for preoperative testing (Benarroch-Gampel, 2012).

A prospective cohort study of 1363 (56.1% female) subjects scheduled for elective surgery in a secondary care hospital was conducted in which abnormal pre-operative tests, significant findings from the medical history and perioperative complications were consecutively recorded. Regression analysis was performed, in order to identify the strongest predictors for perioperative complications. The percentage of abnormalities in pre-operative tests ranged from 1.6% (electrolytes) and 29.7% (echocardiography). Eighty-six (6.3%) trial participants had at least one perioperative complication. The most frequent complications were hypo- or hypertension in 55 cases (4.0%), followed by 20 subjects (1.5%) who suffered from hemodynamically relevant cardiac dysrhythmias, such as supraventricular tachycardia, ventricular tachycardia, bradycardia and ventricular extrasystoles. The binary logistic regression analysis to identify predictors of perioperative complications showed significant results for age, invasiveness of the procedure, history of renal disease or anemia and abnormal ECG. The authors concluded that age, type of surgery and medical history are appropriate predictors of perioperative complications, whereas abnormalities in laboratory tests seem to have restricted ability in predicting adverse perioperative outcome (Fritsch, 2012).

Definitions

Physical Status Classification System: This was established by the American Society of Anesthesiologists (ASA) to provide a basic scale for use in determining an individual’s fitness to undergo anesthesia as follows:

ASA grade I:  A normal healthy person;
ASA grade II:  A person with mild systemic disease;
ASA grade III: A person with severe systemic disease;
ASA grade IV: A person with severe systemic disease that is a constant threat to life

Risk Factors for Coronary Artery Disease (CAD): Long-standing risk factors for the development of CAD have typically included age, blood levels of total and high-density lipoprotein (HDL) cholesterol, blood pressure, cigarette use, diabetes mellitus, and left ventricular hypertrophy on ECG.

Surgical Grades: A classification system adopted by the Guideline Development Group of the National Institute for Health and Care Excellence (NICE, updated 2016) with examples as follows:

Minor surgery: 

Intermediate surgery: 

Major or Complex surgery:

References

Peer Reviewed Publications:

  1. Benarroch-Gampel J, Sheffield KM, Duncan CB, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012; 256(3):518-528. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488956/. Accessed on September 14, 2017.
  2. Fritsch G, Flamm M, Hepner DL, et al. Abnormal pre-operative tests, pathologic findings of medical history, and their predictive value for perioperative complications. Acta Anaesthesiol Scand. 2012; 56(3):339-350.
  3. Rodríguez-Borja E1, Corchon-Peyrallo A1, Aguilar-Aguilar G2, Carratala-Calvo A1. Utility of routine laboratory preoperative tests based on previous results: Time to give up. Biochem Med (Zagreb). 2017 Oct 15; 27(3):030902.
  4. Soares Dde S, Brandao RR, Mourao MR, et al. Relevance of routine testing in low risk patients undergoing minor and medium surgical procedures. Rev Bras Anestesiol. 2013; 63(2):197-201.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Research and Quality (AHRQ). Balk EM, Earley A, Hadar N, et al. Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness. Comparative Effectiveness Review. No. 130. (Prepared by Brown Evidence-based Practice Center under Contract No. 290-2012-0012-I.). AHRQ Publication No. 14-EHC009-EF. Rockville, MD: Agency for Healthcare Research and Quality; January 2014. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm. Accessed on September 19, 2017.
  2. Apfelbaum JL, Connis RT, Nickinovich DG, et al.; American Society of Anesthesiologists (ASA) Task Force on Preanesthesia Evaluation on Standards and Practice Parameters. Practice advisory for preanesthesia evaluation: an updated report by the ASA Task Force on Preanesthesia Evaluation. Anesthesiology. 2012; 116(3):522-538.
  3. Douglas PS, Garcia MJ, Haines DE, ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2011; 24:229-267.
  4. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 2007; 50:e159-242.
  5. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130:2215-2245. Available at: http://circ.ahajournals.org/content/130/24/2215. Accessed on September 15, 2017.
  6. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010; 56:e50-103.
  7. Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol. 2009; 53:2201-2229.
  8. Keay L, Lindsley K, Tielsch J, et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev. 2012;(3):CD007293.
Websites for Additional Information
  1. American Society of Echocardiography. Multiple current guidelines regarding indications for performing echocardiography. Available at: http://asecho.org/guidelines-search/. Accessed on September 18, 2017.
Index

CBC, Complete blood count
CXR, Chest x-ray
Echocardiogram, Resting
EKG, ECG, Electrocardiogram, Resting
Metabolite panel
Preoperative consultation
Preoperative testing
PT/PTT, Prothrombin, Partial Thromboplastin Time
U/A, Urinalysis
WBC, White blood cell count

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

New

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development.