Summary & Overview
CPT 4563F: Perioperative Aspirin for Patients with Coronary Stent
CPT code 4563F documents that a patient with a coronary stent received aspirin within the 24 hours before anesthesia start as part of a perioperative quality measure. This perioperative measure is relevant to surgical safety and cardiovascular risk management because timely antiplatelet therapy around procedures may affect thrombotic and bleeding outcomes. Nationally, documentation of this measure supports quality reporting, informs perioperative medication reconciliation, and can influence hospital quality metrics and payer-directed performance programs.
Key payers covered in this publication include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for perioperative aspirin use in patients with coronary stents, common sites of service where the measure is captured, and how the measure is reported using CPT code 4563F.
The analysis outlines benchmark and reporting considerations, typical clinical workflows that generate the measure, and implications for perioperative quality reporting. Data not available in the input is identified where relevant, and the publication focuses on national implications for documentation and quality measurement rather than state-specific policy.
Billing Code Overview
CPT code 4563F indicates the Perioperative 2 measure: a patient with a coronary stent received aspirin within the 24 hours before anesthesia started. This code is reported by the physician to document perioperative antiplatelet management related to recent coronary stent placement.
Service Type: Perioperative medication management / perioperative quality measure
Typical Site of Service: Hospital inpatient or ambulatory surgery center where anesthesia is administered
Clinical & Coding Specifications
Clinical Context
A 68-year-old male with a history of coronary artery disease status post percutaneous coronary intervention with drug-eluting stent placement 8 months prior presents for elective, non-cardiac surgery (laparoscopic cholecystectomy). Preoperative evaluation identifies that the patient is taking daily aspirin for secondary prevention. Perioperative medication reconciliation confirms aspirin was administered within 24 hours before induction of anesthesia. The anesthesia and surgical teams document timing of last aspirin dose in the preoperative anesthesia record and the perioperative medication reconciliation flowsheet. The perioperative quality measure represented by 4563F is reported by the physician to indicate compliance with the performance measure that patients with coronary stents received aspirin within the 24 hours prior to anesthesia start. Typical workflow steps include preoperative clinic or day-of-surgery medication review, documentation in the anesthesia record, coordination with cardiology if dual antiplatelet therapy is in question, and inclusion of the measure in the perioperative quality reporting bundle.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
24 | Unrelated Evaluation and Management service by the same physician during a postoperative period | Use when an E/M service unrelated to the original procedure is provided postoperatively during the global period. |
| Significant, separately identifiable E/M service by the same physician on the day of a procedure | Use when a distinct E/M evaluation is performed on the same day as the surgical procedure in addition to perioperative care.