Wiki Rotator Cuff Tear Check up

cwilson3333

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If a patient is out of global on a rotator cuff repair, and is in for a follow up exam, what is the appropiate diagnosis to use for this visit? Do I continue to use the rotator cuff tear diagnosis, plus a Z code for after surgery care.
Not always sure which Z codes can be a primary code on the claim.

Thanks
 
It depends on what the documentation indicates. If it was an acute rotator cuff tear (starts with S) and they are still in the healing/recovery phase, you would use the S code with a D at the end (usually). If it was a chronic tear (starts with M) it could be a few options but most likely aftercare following musculoskeletal sx ..... (Z). If there is something else documented or they are having a complication, it would be different.
 
Still wondering about choosing the rotator cuff tear at all, traumatic or non traumatic, since the surgery was done to correct[repair] the tear, and they are not in global anymore, and the doctor has requested they return for a followup visit. No complications or new problems, just a "follow up after surgery" exam to see how the patient is doing. Just need to know if I code the rotator cuff tear a my primary code. As far as Z code, I have been using Z47.89 for orthopedic aftercare.

Thank you for getting back to me.
 
It depends on the documentation in the record. The fact that they are in or out of the global doesn't matter. A patient can still be healing/recovering from a rotator cuff repair much longer than 90 days after.

Refer to the ICD-10 guidelines for Chapter 19 if the reason for the surgery was an injury (acute).
"assignment of the 7th character is based on whether the patient is undergoing active treatment..."
"7th character "D" subsequent encounter is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing and recovery phase"
"The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisoning, where 7th characters are provided to identify subsequent care."

Refer to the ICD-10 guidelines for Chapter 21 and use of the Z codes.
"The aftercare Z codes should also not be used for aftercare for injuries. For aftercare of an injury, assign the actue injury code with the appropriate 7th character (for subsequent encounter)."

In the billing world, the claim would probably go through with the Z47.89 either way unless the clearinghouse or payer has an edit set up to stop it. If an internal auditor in your group or an external auditor was performing a diagnosis audit you would probably get dinged for using the Z code if the initial problem was acute.

More info:
 
Thank you for your "so, so clear" explanation. Now know exactly how to code these "out of global" visits.
Would definitely like to refer back to you when I have my next "orthopedic" question.
Have a great day.:)
 
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