Wiki Aftercare coding

[venugopal]

Hi,

Kindly guide me on how to assign first listed and secondary codes for aftercare diagnosis.
Can the condition for which surgery is performed be assigned as the secondary code?


e.g : 1. Patient presents with thyroid nodule and presents for follow up status post thyroidectomy for consultation and labs(TSH, Calcium total) in an Outpatient setting. Can the diagnosis of thyroid nodule be added as a secondary diagnosis code?

2. Aftercare following FESS surgery(for sinusitis) for Outpatient consultation and Audiometry/Nasal Endoscopy.Can the diagnosis of sinusitis be coded as secondary diagnosis?

what is the time limit for assigning Aftercare codes after surgery? Any guideline for the same?

If we assign only the Aftercare code as first listed diagnosis, how can the labs and procedures done be medically jusitfied in outpatient coding scenario?

 

[mitchellde]

you can never assign a dx that does not exist at the time of the visit.
#1 a thyroidectomy means there is no longer a thyroid and therefore there can be no thyroid nodule
#2 the patient does not have sinusitis at the time of the post op encounter
Aftercare codes are used as long as the provider is doing something due to the surgery such as dressing changes, if it is just a survelliance encounter to see that the patient is doing as expected it is a followup. You can use the acquired absence of the organ for the thyroidectomy but a post op code should be sufficient to support any post op testing.

 

[sguill]

A patient came in for follow-up and is now complaining of pain in the operative area. How would you code orthopedic coding amputation of joint.

 

[mitchellde]

It will depend on exactly what the provider documented.

 

[venugopal]

Thank you for the reply.

Diagnostic coding guideline for outpatient services states that "Certain aftercare codes require secondary dx". Kindly see reference below. Would like to have some clarification as to which diagnosis require a secondary diagnosis code after the aftercare code as first listed.


Aftercare (V51-V58)
? The initial treatment of a disease or injury has
been performed and the patient requires
continued care during the healing or recovery
phase or long-term consequences of the disease
? Generally listed first, but may be additional code
? Certain aftercare codes require secondary dx
code
? Status and aftercare codes may be used together
? Do not use if treatment is directed at current,
acute disease or injury
? Exceptions V58.0, V58.1, V56.x
51

 

[mitchellde]

yes and the codes will direct you to the additional codes needed, such as you use the aftercare following surgery V code followed by the V code for suture removal. You use the aftercare following joint replacement with the status of joint replaced by other means.You use the V code for encounter for chemo followed by the cancer dx code. You just cannot use a dx code for a condition that does not exist at the time of the encounter.