Perioperative medicine is a multidisciplinary field, but the earliest formal pre-operative clinic models came out of anesthesiology. As early as 1949, anesthesiologists described dedicated outpatient assessment clinics; and, by the late twentieth century, both U.S. and U.K. standards placed pre‑anesthesia evaluation squarely within anesthetic practice. Those roots helped today’s perioperative programs—now co‑led with surgery, hospital medicine and nursing—scale from screening to true medical optimization.
WHY PRE-OP CLINICS MATTER
Clinical reliability
Anesthesia-directed clinics reduce avoidable variability: unnecessary testing drops, medication reconciliation improves and day-of-surgery disruptions are less frequent. As pre-op becomes the “front door” for education and optimization, downstream care is more predictable.
Better outcomes and experience
Enhanced recovery after surgery (ERAS) pathways consistently link preop education, nutrition and anemia management, glycemic control, obstructive sleep apnea (OSA) screening and opioid-sparing plans to fewer complications and shorter length of stay. Patients also report a smoother journey when expectations, instructions and contacts are standardized upstream.
A common playbook
The American Society of Anesthesiologists (ASA) Committee on Perioperative Medicine, ACS Strong for Surgery, the Society of Hospital Medicine’s co-management resources, and cross-disciplinary societies such as evidence-based perioperative medicine (EBPOM), American College of Preventative Medicine (ACPM), the ERAS Society and others have all contributed to an ever-increasing body of knowledge making scaling possible.
REAL-WORLD EXAMPLES
New Hanover Regional Medical Center, Wilmington NC
They began their perioperative surgical home (PSH) with the orthopaedic total joint replacement service line. They went from paying a readmission penalty to at one point having the lowest readmission rate in North Carolina. They subsequently scaled their clinic to optimize 16 different surgical service lines.
Duke (PASS/POET Clinic)
This preoperative anesthesia and surgical screening (PASS) clinic serves 90% of their 50,000 cases, and flags 15-20% of patients for additional optimization. Much of that can be done by their perioperative enhancement team (POET). This has resulted in reductions in length of stay, 30-day readmission rate, blood transfusions, along with many other published benefits.
BILLING: WHAT’S BUNDLED VS. WHAT’S BILLABLE
A persistent source of confusion is the difference between the pre-anesthetic evaluation and separate, medically necessary evaluation and management (E/M) services:
Bundled: Under Medicare and most payers, anesthesia base units include the usual pre- and post-operative visits. Your standard pre-anesthetic evaluation is part of the anesthesia service and not separately reportable.
Billable when distinct: If your clinic provides medical optimization that is separate and medically necessary (e.g., chronic disease tuning, medication adjustments, anticoagulation planning, perioperative risk counseling), you may report evaluation and management (E/M) (9920x/9921x) when documentation supports medical necessity and medical decision making (MDM)/time. Teams using physicians and advanced practice providers (APPs) should align to current split/shared rules where applicable.
Don’t forget advance care planning (ACP). For higher-risk patients, pre- op is an ideal moment to clarify goals of care. CPT 99497 (first 16–45 minutes) and 99498 (each additional 30 minutes) are separately billable when time and required elements are documented. Many systems underuse these codes despite clear clinical value.
ARE WE LEAVING MONEY ON THE TABLE?
Yes—many perioperative programs do the work but don’t consistently capture appropriate revenue:
Pre-optimization underbilling
National surgeon surveys show that large majorities do not bill for pre-optimization despite meaningful time spent on risk modification and coordination—signals that similar gaps likely exist in anesthesia-led pathways when E/M is clinically appropriate but not distinguished from the pre-anesthetic exam.
ACP and counseling codes are underused
System-level analyses repeatedly find low uptake of ACP (99497/99498) even in populations where these services are relevant and covered. Pre-op clinics routinely address these topics; failure to document time/content means missed quality and missed revenue.
Bottom line
There’s no published national percentage of pre-op clinics that bill; however, multiple datasets show very low billing rates for billable perioperative services, suggesting most clinics are leaving money on the table while doing the work.
PRACTICAL STEPS TO MATURE YOUR CLINIC
1) Start with the business & billing framework. Stand up governance, compliance program and infrastructure that let you bill when indicated:
- Define which visits can be separate E/M vs. bundled anesthesia evaluations.
- Create distinct note types/headers (e.g., “Perioperative Medicine E/M”) and smart-phrases that prompt for medical decision-making (MDM) or time documentation.
- Build order sets and charge-capture workflows for E/M and ACP; map who can bill what (MD/DO vs. APP) and when split/shared applies.
- Educate coders/clinicians; run monthly audits with feedback loops.
2) Define the clinical scope. Publish a one-page charter: who gets seen, which risks are targeted, what testing is indicated (and what is not), and where optimization handoffs go.
3) Build standard content. Smart phrases and checklists for patient education; medication holds/bridges; nutrition and anemia; diabetes and OSA algorithms; opioid-sparing plans; and perioperative anticoagulation pathways.
4) Operationalize documentation. Distinguish the pre-anesthetic evaluation from any separate E/M visit (problem-oriented documentation; explicit time/MDM; clear chief complaint/assessment). Add quick-selects for ACP and counseling with required elements.
5) Measure and iterate. Track timeliness, adherence to testing algorithms, LOS, complications, patient-reported experience—and the rate of appropriate E/M/ACP capture. Share run-charts with surgeons, nursing, hospitalists, and executives.
TAKEAWAY
Pre-operative clinics are now the operational center of perioperative medicine. When anesthesiologists lead these clinics—anchored to ASA Committee guidance and ERAS/EBPOM/ACPM principles, aligned with surgeons and hospitalists, and supported by clean documentation—they deliver safer care and better patient experience. And when legitimately distinct services are captured as E/M (and ACP when appropriate), the clinic sustains itself on the value it creates.
References
1. Lee JA. The anaesthetic out‑patient clinic. Anaesthesia.1949.
2. American Society of Anesthesiologists. Basic Standards for Preanesthesia Care (originally approved 1987; periodically updated). https://www.asahq.org/standards-and-practice-parameters/basic-standards-for-preanesthesia-care
3. Association of Anaesthetists. Pre‑operative assessment and patient preparation – the role of the anaesthetist (guideline). https://anaesthetists.org/Home/Resources-publications/Guidelines/Pre-operative-assessment-and-patient-preparation-the-role-of-the-anaesthetist-2
4. Sauro KM, et al. Enhanced Recovery After Surgery Guidelines and Outcomes: Meta-Analysis of RCTs. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2820097
5. American College of Surgeons. Strong for Surgery Implementation Guide. https://uploads-ssl.webflow.com/6421bdde8f7e3808010a5ae3/643fff79427b9cb5730c5077_Toolkit-Strong-For-Surgery-Implementation-Guide-American-College-of-Surgeons.pdf
6. Evidence Based Perioperative Medicine (EBPOM). https://www.ebpomglobal.org/
7. American College of Perioperative Medicine (ACPM). https://acpm.health/
8. Duke Department of Anesthesiology. Perioperative Enhancement Team (POET) Clinics. https://anesthesiology.duke.edu/cpop/patient-care
9. McDonald SR, Heflin MT, Whitson HE, Dalton TO, Lidsky ME, Liu P, Poer CM, Sloane R, Thacker JK, White HK, Yanamadala M, Lagoo-Deenadayalan SA. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg. 2018 May 1;153(5):454-462.
10. American Society of Anesthesiologists. PSH Implementation Guide. American Society of Anesthesiologists website. Updated May 27, 2022.
11. American Society of Anesthesiologists. Distinguishing Between a Pre‑Anesthesia Evaluation and a Separately Reportable E/M Service. https://www.asahq.org/quality-and-practice-management/managing-your-practice/timely-topics-in-payment-and-practice-management/distinguishing-between-a-pre-anesthesia-evaluation-and-a-separately-reportable-evaluation-and-management-service
12. Centers for Medicare & Medicaid Services (CMS). Advance Care Planning MLN Fact Sheet (ICN MLN909289). https://www.cms.gov/files/document/mln-advanced-care-planning.pdf
13. CMS. NCD 210.4.1 – Counseling to Prevent Tobacco Use. https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=342
14. CMS. National Correct Coding Initiative (NCCI) Policy Manual – Chapter II: Anesthesia Services (CPT 00000–01999). https://www.cms.gov/files/document/chapter2cptcodes00000-01999final11.pdf
15. Grosso MJ, et al. Surgeons’ Preoperative Work Burden Has Increased Before Total Joint Arthroplasty: A Survey of AAHKS Members. 2020. https://www.aahks.org/wp-content/uploads/2020/02/Surgeons’-Preoperative-Work-Burden-Has-Increased-Before-Total-Joint-Arthroplasty-A-Survey-of-AAHKS-Members.pdf
16. Bader AM, et al. Nuts and bolts of preoperative clinics: the view from three institutions. Cleve Clin J Med. 2009;76(Suppl 4):S104‑S111. https://www.ccjm.org/content/ccjom/76/10_suppl_4/S104.full.pdf
17. Society of Hospital Medicine. Building and Sustaining Co‑Management Programs in Hospital Medicine (resource guide). https://www.hospitalmedicine.org/practice-management/program-administration/building-and-sustaining-co-management-programs-in-hospital-medicine-a-technical-report-and-operational-guide/
Dr. Chris Steel is board-certified anesthesiologist. He served as the medical director for the ASA’s Perioperative Surgical Home Learning Collaborative 2020 and Chaired the PSH Implementation Guide Workgroup. Dr. Steel has been Director of Anesthesia Services at White River Health for over 13 years, served as the Chief Quality Officer, Chief of Staff, Chief Medical Officer, and the Interim President and Chief Executive Officer. He is also currently the Chief Medical Consultant for E1 Precision Consulting and Long Game Health whose clients currently include: medical clinics, health systems, anesthesia management companies, anesthesiology groups, as well as non-healthcare-related companies. He can be reached at csteel@longgame.com.