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Wiki aftercare coding question

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micki127

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Hello,

Patient is 6 weeks out from shoulder arthroscopy still in post op period and comes into office for just an exam. How would you code this? if you use V58.49 then you need another aftercare code and I am not sure what to use. Any help would be great.

Thank you:)
 
It would depend on what he is coming in for? Is here there still following up from his surgery, I would use v67.09
 
Yes, the patient was having a follow up to the surgery. Notes do not discuss anything other than an exam. No dressing change or anything else.
 
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