Encounter for preprocedural laboratory examination
Other postprocedural complications and disorders of digestive system
What is the correct ICD-10-CM code to report the External Cause? Your Answer: V80.010S The External cause code is used for each encounter for which the injury or condition is being treated.
The diagnostic code you use needs to be identical to that used by the surgeon. The date of service should correspond to the date of the surgery. Use the same surgical CPT procedure code used by the surgeon, but add the -55 modifier to signify that you are rendering the postoperative care.
Aftercare codes are found in categories Z42-Z49 and Z51. Aftercare is one of the 16 types of Z-codes covered in the 2012 ICD-10-CM Official Guidelines and Reporting.
Other specified postprocedural states2022 ICD-10-CM Diagnosis Code Z98. 890: Other specified postprocedural states.
For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.
18.
ICD-10 Code for Other specified postprocedural states- Z98. 89- Codify by AAPC. Factors influencing health status and contact with health services. Persons with potential health hazards related to family and personal history and certain conditions influencing health status.
Z48. 815 - Encounter for surgical aftercare following surgery on the digestive system | ICD-10-CM.
Post-operative visits should be reported with CPT code 99024 when the visit is furnished on the same day as an unrelated E/M service (billed with modifier 24).
99024 - Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.
Z aftercare codes are used in office follow-up situations in which the initial treatment of a disease is complete and the patient requires continued care during the healing or recovery phase or for long-term consequences of the disease.
Postoperative pain can be divided into acute pain and chronic pain. Acute pain is experienced immediately after surgery (up to 7 days) and pain which lasts more than 3 months after the injury is considered to be chronic pain.
9: Fever, unspecified.
Postoperative pain not associated with a specific postoperative complication is reported with a code from Category G89, Pain not elsewhere classified, in Chapter 6, Diseases of the Nervous System and Sense Organs. There are four codes related to postoperative pain, including:
The key elements to remember when coding complications of care are the following: Code assignment is based on the provider’s documentation of the relationship between the condition and the medical care or procedure.
Determining whether to report postoperative pain as an additional diagnosis is dependent on the documentation, which, again, must indicate that the pain is not normal or routine for the procedure if an additional code is used. If the documentation supports a diagnosis of non-routine, severe or excessive pain following a procedure, it then also must be determined whether the postoperative pain is occurring due to a complication of the procedure – which also must be documented clearly. Only then can the correct codes be assigned.
Postoperative pain typically is considered a normal part of the recovery process following most forms of surgery. Such pain often can be controlled using typical measures such as pre-operative, non-steroidal, anti-inflammatory medications; local anesthetics injected into the operative wound prior to suturing; postoperative analgesics;
Only when postoperative pain is documented to present beyond what is routine and expected for the relevant surgical procedure is it a reportable diagnosis. Postoperative pain that is not considered routine or expected further is classified by whether the pain is associated with a specific, documented postoperative complication.