Wiki aftercare diagnosis 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.

 

[venugopal]

Thanks Michelle