Avoid S Codes for a Fracture That Has Already Healed
Question: An established patient presented for a global radiology follow-up office visit. The patient had a total hip arthroplasty one year ago that was complicated three months post-op from a fall and an acetabular fracture. The patient encounter assessment states, “Stable right total hip arthroplasty” and “Healed pelvic fractures.” I think I should report some Z codes for the encounter, but I’m also wondering if an S code with 7th character “D” is appropriate. Can someone help? Kentucky Subscriber Answer: You don’t want to use an S code with 7th character “D,” such as S32.401D (Unspecified fracture of right acetabulum, subsequent encounter for fracture with routine healing), with this encounter because the injury has already healed. The 7th character “D” is reserved for when the patient is still in the healing and recovery phase. Assign Z47.1 (Aftercare following joint replacement surgery) and Z96.641 (Presence of right artificial hip joint) for the encounter. You might want to also consider Z87.81 (Personal history of (healed) traumatic fracture) to accurately explain the visit. Of course, you could check with the payer to confirm which Z codes it prefers. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
