ICD-9 coding for aftercare

[beccy]

When having your post-op visit after surgery would you code V58.78 alone or with the surgical Dx in the secondary position.

[mitchellde]

You will not code the condition that required the surgery after the surgery is complete. It is aftercare or followup. Aftercare is when you are still managing some portion of the patients surgical care and the aftercare code should be followed with the code for that care given, such as attention to a device or suture removal, follow up (V67.x) is for a survellience of the patient just to make sure all is going ok. Remember the dx is the patient's so if the condition has be resolved with surgery, do not give it to them again.

[tammster]

I know that I've seen this question answered MANY times. I am trying desperately to find a source for this guideline, as my doctors want to continue to bill the original diagnosis (as the primary) and the aftercare dx as well.

The guideline from the book was not convincing enough - does anybody have any suggestions?

[btadlock1]

These ICD-9 conventions are the most applicable:

For accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-9-CM codes to describe all of these.

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (Outpatient, if visit is unrelated to follow-up of resolved condition)

Previous conditions
If the physician has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some physicians include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.
However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (Inpatient only)

Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare V code should not be used if treatment is directed at a current, acute disease or injury, the diagnosis code is to be used in these cases. Exceptions to this rule are codes V58.0, Radiotherapy, and V58.1, Chemotherapy. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy or chemotherapy for the treatment of a neoplasm. Should a patient receive both chemotherapy and radiation therapy during the same encounter code V58.0 and V58.1 may be used together on a record with either one being sequenced first.
Certain aftercare V code categories need a secondary diagnosis code to describe the resolving condition or sequelae, for others, the condition is inherent in the code title.

The follow-up codes are for use to explain continuing
surveillance following completed treatment of a disease,
condition, or injury. They infer that the condition has been
fully treated and no longer exists. They should not be
confused with aftercare codes which explain current
treatment for a healing condition or its sequelae.

Follow-up
codes may be used in conjunction with history codes to
provide the full picture of the healed condition and its
treatment. The follow-up code is sequenced first, followed
by the history code.
A follow-up code may be used to explain repeated visits.
Should a condition be found to have recurred on the follow-
up visit, then the diagnosis code should be used in place of
the follow-up code.The follow-up V code categories:
V24 Postpartum care and evaluation
V67 Follow-up examination

Hope that's helpful!

[cfitz842]

I know you can use the followup or aftercare codes when patient is discharged from hospital, but what about the day after surgery or the second day after surgery when the patient is still in the hospital, are these V codes applicable then? Or does the dx code for the surgery apply?

[btadlock1]

I'd say the aftercare would apply. It's not necessarily for discharged patients, like the previous condition codes - it's for ongoing treatment during the healing period after initial treatment of a disease/injury, to manage the recovery and treat aany side effects that patinet may suffer from - it would be the post-surgical period care. It specifically says that if the initial problem is still being treated after surgery/treatment, the code for the disease/injury would be used instead. It also says that some aftercare V-codes require a secondary diagnosis to describe the resolviing or healing condition, and I'm sure that those have instructions in the tabular section. (But I don't have my book with me).

[mitchellde]

Even in the inpt setting after surgery you ue the follow up codes for the physician.

[cfitz842]

Thank you both. The part about "the initial problem still being treated..." in the guidelines is what was confusing me. I really appreciate the timely answers.