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ICD-10-CM Coding for Aftercare
• Aftercare for injuries, during the healing and recovery phase, should be coded with the injury code and the appropriate 7th character for subsequent encounter rather than a Z code. • NOT reported if treatment is currently being directed at an acute disease or acute injury. Example: Return visit for unspecified fracture of the lower end
Coding for Fracture Care •“The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation (reduction) and stabilization (fixation or immobilization).” • CPT Coding Guidelines, Musculoskeletal System 20 Coding for Fracture Care •Where is the site of the fracture? •Was treatment open
Use Z codes to code for surgical aftercare. Z47. 89, Encounter for other orthopedic aftercare, and.
Code Z47. 1 (aftercare following joint replacement surgery) is used during the follow-up phase of any joint replacement surgery, even if the replacement was for treatment of a fracture. It must be accompanied by a code from subcategory Z96. 6, which identifies the specific joint location and laterality (Table 1).
ICD-10 code Z48. 89 for Encounter for other specified surgical aftercare is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
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.
Aftercare visit codes are assigned in situations in which the initial treatment of a disease has been performed but the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.
If the spinal fusion was done during surgery then use the Z98. 1 code. If the patient has a natural fusion of the spine or (ankylosing spondylitis) which causes the spine to fuse then use the M43.
Z47.89ICD-10-CM Code for Encounter for other orthopedic aftercare Z47. 89.
Follow-up. The difference between aftercare and follow-up is the type of care the physician renders. Aftercare implies the physician is providing related treatment for the patient after a surgery or procedure. Follow-up, on the other hand, is surveillance of the patient to make sure all is going well.
For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47. 1, Aftercare following joint replacement surgery, as the first-listed or principal diagnosis.
The patient's symptoms have resolved and the physician is not evaluating the condition. This is a notation of a resolved condition; it should not be assigned as an additional code.
Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis.
Z47.89ICD-10-CM Code for Encounter for other orthopedic aftercare Z47. 89.
The general consensus is to use the fracture care codes designated as “closed treatment without manipulation” and bill the initial E/M with modifier 57.
ICD-10 code Z48. 81 for Encounter for surgical aftercare following surgery on specified body systems is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
ICD-10-CM defines subsequent encounters as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase.
Reason for encounter: Aftercare for traumatic fracture is reported with code S82.224D, Nondisplaced transverse fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing.
Aftercare for injuries is reported with a V-code in ICD-9-CM. However, aftercare of injuries in ICD-10-CM is captured with the seventh character “D,” specifically denoting routine care following most injuries. For fractures, additional seventh characters for subsequent encounters apply, depending on whether the fracture is open or closed and whether the healing is routine or delayed, with nonunion or malunion.
Aftercare following explantation of a joint prosthesis is reported with a code from category Z47, denoting orthopedic aftercare. Aftercare following explantation of a joint prosthesis (Z47.3-) may be reported for a staged procedure or an encounter for evaluation of planned insertion of a new joint prosthesis following prior explantation of a joint prosthesis. In ICD-10-CM, aftercare for explantation of a joint prosthesis is specific to site.
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. Aftercare visit codes cover situations occurring when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or care for the long-term consequences of the disease.
The codes for factors influencing health and contact with health services represent reasons for encounters. In ICD-10-CM, these codes are located in Chapter 21 and have the initial alpha character of “Z,” so codes in this chapter eventually may be referred to as “Z-codes” (just as the same supplementary codes in ICD-9-CM were referred to as “V-codes”). While code descriptions in Chapter 21, such as aftercare, may appear to denote descriptions of services or procedures, they are not procedure codes. These codes represent the reason for the encounter, service or visit, and the procedure must be reported with the appropriate procedure code.
When the reason for an encounter is aftercare following a procedure or injury, the 2012 ICD-10-CM Official Guidelines and Reporting should be consulted to ensure that the correct code is assigned. Codes for reporting most types of aftercare are found in Chapter 21. However, aftercare related to injuries is reported with codes from Chapter 19, using seventh-character extensions to identify the service as aftercare.
Aftercare codes should be used in conjunction with other aftercare codes, diagnosis codes and/or other categories of Z-codes to provide better detail on the specifics of the aftercare encounter/visit, unless otherwise directed by the classification.
V54.10 is a legacy non-billable code used to specify a medical diagnosis of aftercare for healing traumatic fracture of arm, unspecified. This code was replaced on September 30, 2015 by its ICD-10 equivalent.
A fracture is a break, usually in a bone. If the broken bone punctures the skin , it is called an open or compound fracture. Fractures commonly happen because of car accidents, falls or sports injuries. Other causes are low bone density and osteoporosis, which cause weakening of the bones. Overuse can cause stress fractures, which are very small cracks in the bone.
V54.17 is a legacy non-billable code used to specify a medical diagnosis of aftercare for healing traumatic fracture of vertebrae. This code was replaced on September 30, 2015 by its ICD-10 equivalent.
A fracture is a break, usually in a bone. If the broken bone punctures the skin , it is called an open or compound fracture. Fractures commonly happen because of car accidents, falls or sports injuries. Other causes are low bone density and osteoporosis, which cause weakening of the bones. Overuse can cause stress fractures, which are very small cracks in the bone.