Wiki Aftercare s/p 1 yr from surgery

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lhoot

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Requesting some help on an aftercare scenario. Pt is being seen 1 year status post hip replacement. X-rays are done. All is well with the hip replacement and pt is to return for re-check as needed. Pt also mentioned some low back and buttock pain, unrelated to the hip replacement nothing further is done, planned or addressed. Diagnoses for outpatient visit are listed as status post total hip replacement and inflammation of left sacroiliac joint. Should aftercare code Z47.1 be coded along with the codes for the stated diagnoses?

Laura
 
Which other diagnoses? is the sacroiliac inflammation separate diagnosis from the pain the pt mentioned? I am sorry, I am asking this because the scenario states that the pain the pt mentioned is unrelated to the hip replacement and the x-ray was all well. It is a little bit confusing. Otherwise, if you have a definite unrelated diagnosis you can report it along with the reason for the encounter. Make sure to use additional code to identify the joint per ICD10 rule.
 
Sorry, the statement I made about the low back pain is a little confusing. Yes, the sacroiliac pain is unrelated, not due to, the hip replacement. Dr. thinks patient is having some other lumbar issues that might be causing this. The reason for visit is stated as "presents repeat evaluation 1 year status post left total hip arthroplasty." The diagnoses listed in the Assessment section of the visit note are 1. Status post total hip replacement, left and 2. Inflammation of left sacaroiliac joint. My question is, should the diagnoses be Z96.642, M46.1 or Z47.1, Z96.642, M46.1

In this case, is this still considered the healing and recovery phase of treatment? It's been a year since surgery. I guess my bigger question is what determines the end of the healing and recovery phase?
 
For after care there isn't time limit since on the ICD10 guidelines if you have noticed it says: Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, OR FOR THE LONG-TERM consequences of the disease. Your scenario clearly states that the patient presents for repeat evaluation. The reason for the encounter is for evaluation of the hip arthroplasty which falls in Z47.1 and you have an other dx sacroiliac inflammation you code that too. You will use Z96.642 to fully describe you aftercare condition. You probably have the doubt because in the assessment, it stated only the status code which is just informative as the pt had the replacement. For me it is still not clear why the reason for the encounter didn't matter for you.
 
Thank you so much for your help and further explanation.
Physician coding is a new realm for me, so I'm overthinking a bit.
Thank you again.
 
lhoot said:
Thank you so much for your help and further explanation.
Physician coding is a new realm for me, so I'm overthinking a bit.
Thank you again.
Click to expand...
The previous coder is correct. You will use Z47.1 as the primary code and Z96.642 or whatever the code is for the joint that is replaced second. Not sure if you are aware but joint replacements need to be monitored. They can become loose, move or break. So performing X-rays every year or so is medically necessary to make sure the implants are in place.
 
Orthocoderpgu said:
The previous coder is correct. You will use Z47.1 as the primary code and Z96.642 or whatever the code is for the joint that is replaced second. Not sure if you are aware but joint replacements need to be monitored. They can become loose, move or break. So performing X-rays every year or so is medically necessary to make sure the implants are in place.
Click to expand...

That makes perfect sense.
Thank you so much for the clarification on the necessity for continued monitoring.
Laura
 
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