Hi Amet
Dx Z01.818 is first listed dx code so can use as primary dx but add the definitive dx code as 2nd.
I hope helped you with this data
Lady T
Z01.818 is not the correct diagnosis for a postoperative visit, it is for PRE-operative.
Depending on the scenario, it could be appropriate to code the postop, the procedure/problem diagnosis, a history of, or a combination of those.
Example1: Patient has an umbilical hernia that is surgically repaired. Procedure has 0 day global.
Postop visits I would code with only the postop diagnosis and 99212-99215 based on level of service provided. Coding a hernia that is no longer present would not seem correct. Coding a history of is more appropriate.
Example2: Patient has a fibroid that is removed via laparoscope. Procedure has a 90 day global.
Postop visits would be 99024 (not billed to insurance). Again, the only diagnosis that seems correct is the postop care and history of.
Example3: Patient has a rotator cuff tear repaired surgically. Procedure has 90 day global.
During postop 7 days later, patient mentions pain in his ankle, which the provider also evaluates and treats. I would code 99212-99215-24 based on level of care provided for ankle. Diagnosis 1 ankle problem. Diagnosis 2 postop. Diagnosis 3 torn rotator cuff. It has not yet healed, so that problem does still exist.
If the coding guidelines state "code additional" on your postop code, I would code the postop followed by the additional code. If the coding guidelines state "code first" (many of the history codes do), then that is what should be primary.
Note - When it is a 99024 only and not billed to insurance, I do not require my coders to spend time determining all the
diagnosis codes and they are permitted to use something like Z09 only even if it doesn't follow all coding guidelines. I want them to focus their efforts on accurate coding that results in payments.