Wiki S versus D

[HeidiLynn]

Pt was seen for Sequela stress fracture now healed. Do I code with the D now or keep as the S? M84.374S was first DOS now healed not sure which way to go. Thanks

 

[mitchellde]

Neither. If has healed with no after effects then there is no sequela. Use Z09 for follow up.

 

[HeidiLynn]

well that was so simple I way over thought that. haha Thank you.

 

[AlanPechacek]

Your original query does not say what the original problem/diagnosis was for which the Stress Fracture was the Sequela, but if the patient is still undergoing "active follow-up" for the Stress Fracture, and if it is healing as expected, without apparent difficulty, and the patient has not yet been discharged from care for the Stress Fracture, then D would still be the correct 7th character. If the patient has completely healed and recovered from the Stress Fracture, and is returning to see the doctor for "Medical Surveillance following completed treatment," then the Z09 would be correct, plus Z87.312 (Personal History of healed Stress Fracture) as per directed by the Coding Note for Z09.

Respectfully submitted, Alan Pechacek, M.D.