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Hello,
I am a new Home Health coder. I am working on codes for aftercare for a hip replacement. The procedure was May 26th, a little over a month ago. The clinician listed residual weakness and gait abnormality as diagnoses. My question is, at what point are these separately coded and not considered a normal part of the surgery aftercare?
Thanks
 

JMarieBrandt

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It depends on the documentation, you will have to go thru office visit notes, or interpretation of imaging to see if the MD calls the replacement "healed" or if it is still healing. If he indicates it as healed, you will code the signs or symptoms. Otherwise you will continue to code aftercare.

I know that's not a pretty answer, but...
 

AlanPechacek

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The Codes for Orthopedic Aftercare following a Total Hip Replacement are Z47.1, supplemented with Z96.64 _ for Presence of Orthopedic Joint Implants (6th Character for laterality). I would use these until the 90 day Global Period for recovery from a major procedure is complete. Most patients are going to have some "weakness and gait abnormality" after hip replacement and until they have recovered. Hopefully the patient is getting PT Rx. At this point, "weakness and gait abnormality" are "reasons" for the patient getting Home Health care, but they are not true "diagnoses" unless they persist or continue well after the expected recovery time, at which time the would become "diagnoses" that would justify continued active care and treatment, i.e. Home Health Care and/or Home or Outpatient PT Rx to resolve them.

Hope this helps.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
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Cpc

My question is related to AFTERCARE CODING...I work for an Internist who is frequently called in for patients who have surgery for spinal stenosis because the patients also have various chronic diseases. My question is: should I code Z48.811 or Z98.890? I am coding only for the internist's in patient services. Any clarification would be greatly appreciated. Thanks!
 

cfitzgibbons

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My question is related to AFTERCARE CODING...I work for an Internist who is frequently called in for patients who have surgery for spinal stenosis because the patients also have various chronic diseases. My question is: should I code Z48.811 or Z98.890? I am coding only for the internist's in patient services. Any clarification would be greatly appreciated. Thanks!

You would code the reason why the patient is being seen. You would code a personal history for the spinal issues.
 
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