Aftercare Z Codes

melissa.reed22

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There is some debate about aftercare coding. For an example let's say a patient has a traumatic fracture, ORIF is performed, and now the patient comes back to the clinic 6 months later for a follow up visit. Some say the S codes should no longer be used even with a D for the 7th character because they're only for acute traumatic fractures, and at this point 6 months out if it's still not healed it's becoming a chronic issue. One person says to use Z09 only, but it's not acceptable as a primary diagnosis. How does everyone else code this type of thing?
 

shecodes

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The S-code will remain with that patient for as long as there is treatment taking place for that injury.

Initial visit - A
2 week follow up - D
Surgery - A

If 6 months from now, a fracture is still not healing, it's time to query the doctor to find out if this is a non-union or delayed healing that should be documented/coded. Only the provider can determine when an injury has become chronic. We cannot just assume that because it's been 6 months it's chronic. We code based on documentation.

Only once an injury is healed completely and there is no more treatment being directed at that injury, and is documented as such, would you then change to the z09. I have not encountered documentation or denials supporting your statement that z09 is not acceptable as a primary diagnosis.
 

mitchellde

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That document and the lists were created for inpatient code reporting. It does not apply to physician or outpatient clinics. Z09 is acceptable first listed or a physician encounter. Follow up is not the same as aftercare so the guideline regarding aftercare Z codes is not applicable if the fracture has healed and this is a follow up encounter. Z09 is appropriate.
 

AlanPechacek

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The time frame of 6 months is not the issue. If the patient is still under observation/follow-up care for the original fracture and surgical treatment, then the Acute Fracture Diagnosis S Code remains in place, and only the 7th Character changes depending on the healing process. Your query indicates that the fracture hasn't completely healed, which would mean it is either a "Delayed Healing" or "Nonunion" situation. Assuming the original fracture was closed, the 7th Character would be D for normal/routine healing, G for delayed healing, or K for nonunion. Your physician is going to have to "make the call" as to whether it is "Delayed Healing" or "Nonunion" in order to assign the correct one. Unless there is some other complication of treatment not identified in your note, 7th Character S does not apply. The 7th Character for "abnormal healing" remains in place until treatment is complete and the patient discharged from care, even if additional surgical treatment to the abnormally healing fracture is rendered. I refer you to icd10orthocoder.com where I have a Blog regarding 7th Characters, integrated with the Gustilo Classification of open fractures. Click on the Blogs Tab, scroll through the list of Blogs, then click on the Blog for 7th Characters and the full Blog will open up.

As for Z Codes, these Codes are "Reasons for Encounters," and are not in and of themselves Diagnosis Codes. Also, they are not meant for use for fracture aftercare while the fracture care/follow-up/observation is still in progress. Once the patient has healed and recovered to the best possible level of recovery, and has been discharged from further care and follow-up, the Z09 (Encounter for Follow-up Examination after completed treatment for a condition other than malignant neoplasm) could be applied if the patient returns for some reason, possibly with questions and/or concerns about their previous injury, but without necessarily having any new symptoms or complaints. There is a Coding Note/Directive: Use additional code to identify any applicable "History of" disease code for Z09. In the case of a healed traumatic fracture, this would be Z87.81.

Hopefully this helps clarify this issue for you.

Respectfully submitted, Alan Pechacek, M.D.
 
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