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solocoder

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Would anyone count a "status post (fill in the blank)" as Chief Complaint?
Could a status code even be used as a primaray dx?

Here is an example.


Patient presents to the clinic today, he is s/p open fifth ray amputation right foot.

States he is doing well. He has had no drainage from his wound. He does have an appointment for his CROW walker pending his insurance approval. Patient denies nausea, vomiting, diarrhea, fever, chills, shortness of breath, calf pain or chest pain

Neurovascular status is unchanged.
The wound is pre ulcerative today. It is covered by hyperkeratotic tissue.
The edema to the foot remains resolved
Homan's sign is negative

Assessment:
S/P open fifth ray amputation right foot, healing satisfactorily
Pre ulcerative callus
Acute charcot right foot, stable
 
Chapter 18 Classification of Factors Influencing Health Status: There is a note that states: This chapter specific guidelines provide additional information about the use of V codes for specific encounters. example 18:3 Status > subcategories
V49.6, V49.7 are to be used only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment which the patient is dependent.
The Dx code I would selected based on the medical documentation you provided would be V49.72.

But do consider Mitchell diagnosis recommendation. ;) Thanks

Janie R
 
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