Wiki Fracture care in office after ER visit

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I'm not sure if this scenario is aftercare (V code) or active treatment (injury code). In the Ch. 17 guidelines, it states some examples of active treatment include "evaluation and treatment by a new physician." Does this pertain to PCP seeing patient after the ER doc saw and treated patient? PCP's note as follows:

CC: ER followup for wound evaluation of great toe nondisplaced tuft fracture with subungual hematoma which happened 3 days ago. Pt is taking Keflex and Norco. It was recommended the patient follow up with ortho in one week with daily dressing change and crutches for ambulation.

Exam of right great toe: Severe and diffuse bruising with crushing injury.

Dx: Injury of toe, 959.7.

Plan: Changed dressing. Referred to ortho. Continue Keflex.

This is the first time this doctor is seeing this injury, so do I use the injury code? (My other question is why this provider chose injury vs fracture...which do I use?) But this injury has already been evaluated and treated, and now a dressing change is done, so is this routine aftercare? And would I use V58.30 as an additional code or as a primary diagnosis?

Thanks so much for your help! I've been searching similar posts, reading guidelines, etc., but this is new to me and I want to make sure I'm getting it right.
 
Once the injury has been treated and is in a healing status, and presents to your office for aftercare treatment it is coded with the V code for healing fx. This is stated in AHA coding clinics and in the guidelines it states that you do not cod a condition is does not exist. These are patient cides so you code the dx from the patient perspective as documented by the provider. The provider states the patient is receiving dressing changes and general Ftercare treatment. The dx is not based on the provider encounter. For ICD-10 CM this is the same logic, you would not code this as an initial encounter it will be a subsequent with routine healing.
 
Thank you, Debra, for your explanation! I just wasn't sure, as this is a different physician seeing it for the first time. But I can see the fracture has already received initial treatment.

Would I use V54.19 (aftercare for healing traumatic fracture of other bones) or V58.30 (encounter for dressing change) as primary diagnosis? Or would I use both codes or would that be redundant?

Once again, thanks (as I add to my notes)!
 
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