Wiki Z42.8 Encounter for other plastic and reconstructive surgery following medical

[natashalage]

Hello, I am a new pro fee coder and will greatly appreciate your expertise with using Z42.8. Recently, I coded a few cases with Z42.8 and I was wrong, I am not convinced with the answer given and therefore, would like to get your opinion. Case: pt is coming to see a plastic surgeon to discuss a plastic surgery After healed medical procedure for cleft palate (for example). The doctor is saying that the pt is a good candidate and the surgery can be scheduled/considered. I used Z42.8 as the prim dx and then Q code. I was told that I cannot use Z42.8 because pt is not having surgery 'right now' or the office note doest not say' Pre-op visit". But to me, pt and doctor are discussing the plastic surgery. Pt is New to the plastic doctor. May I use Z42.8 as prim? Z42.8- Encounter for other plastic and reconstructive surgery following medical procedure or healed injury. Another case could be: pt has mastectomy done and is coming for discussing a plastic surgery.
Thank you in advance.

 

[mitchellde]

Hello, I am a new pro fee coder and will greatly appreciate your expertise with using Z42.8. Recently, I coded a few cases with Z42.8 and I was wrong, I am not convinced with the answer given and therefore, would like to get your opinion. Case: pt is coming to see a plastic surgeon to discuss a plastic surgery After healed medical procedure for cleft palate (for example). The doctor is saying that the pt is a good candidate and the surgery can be scheduled/considered. I used Z42.8 as the prim dx and then Q code. I was told that I cannot use Z42.8 because pt is not having surgery 'right now' or the office note doest not say' Pre-op visit". Buut to me, pt and doctor are discussing the plastic surgery. Pt is New to the plastic doctor. May I use Z42.8 as prim? Z42.8- Encounter for other plastic and reconstructive surgery following medical procedure or healed injury. Another case could be: pt has mastectomy done and is coming for discussing a plastic surgery.
Thank you in advance.

The Z48 code would be incorrect for the office encounter. Also if the cleft palate is repaired you no longer use the Q code as the congenital anomaly no longer exist. I would us the Z09 code follow by a code for “history of”.