Radiology Coding Alert

Question: A patient had surgery on their left foot. During a post-operative visit, the radiologist captured two-view X-rays of the foot and noted displacement of the internal fixation device. We reported T84.223A as the diagnosis code for that encounter. The surgeon planned a follow-up surgery to correct the displacement.

Would we use T84.223D for the follow-up surgery?

Arizona Subscriber

Answer: You will continue to assign T84.223A (Displacement of internal fixation device of bones of foot and toes, initial encounter) for the encounter. Even though the patient returned for a post-operative follow-up visit and the surgeon will be performing a follow-up surgery to correct the internal fixation device’s displacement, the patient is still seeking active treatment for their condition.

Another way of looking at it is to use 7th character A for active treatment. This may occur over multiple encounters depending on what was done. In this case, active treatment includes the initial examination, diagnostic X-rays, first surgery, and the follow-up surgery.

Once the internal fixation device is repositioned, and the patient presents for a routine follow-up appointment for the surgeon to evaluate the healing process, then you’ll assign T84.223D (Displacement of internal fixation device of bones of foot and toes, subsequent encounter).