FractalMind
Guru
Hello there!
My question is: if the lumbar disc herniation was repaired a few days ago and the patient is still in the healing/recovery phase, do we still code M51.16 or do we report the history code?
Physician reported diagnoses Z48.811 & M51.16 for this post-op visit S/P lumbar microdiscectomy.
Encounter date: 4/5/24
70 year old female s/p left lumbar 1.2/3 hemilaminectomy and durotomy repair on 3/28/24 who presents with leg pain which is most likely postoperative pain that will resolve with time; however, I will order outpatient MRI to assess for any postop changes. Wound evaluated, CDI. Post-op wound care instructions advised and given to patient. Continue routine health care management with Primary Care Doctor for non-surgical proactive care management.
Diagnoses reported by neurosurgeon: Z48.811, M51.16.
My question is: if the lumbar disc herniation was repaired a few days ago and the patient is still in the healing/recovery phase, do we still code M51.16 or do we report the history code?
Physician reported diagnoses Z48.811 & M51.16 for this post-op visit S/P lumbar microdiscectomy.
Encounter date: 4/5/24
70 year old female s/p left lumbar 1.2/3 hemilaminectomy and durotomy repair on 3/28/24 who presents with leg pain which is most likely postoperative pain that will resolve with time; however, I will order outpatient MRI to assess for any postop changes. Wound evaluated, CDI. Post-op wound care instructions advised and given to patient. Continue routine health care management with Primary Care Doctor for non-surgical proactive care management.
Diagnoses reported by neurosurgeon: Z48.811, M51.16.