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status post

  1. #1
    Springfield, Mo
    Default status post
    Medical Coding Books
    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

    S/P open fifth ray amputation right foot, healing satisfactorily
    Pre ulcerative callus
    Acute charcot right foot, stable
    solocoder CPC

  2. #2
    Columbia, MO
    Use either the V67.- code for follow up or the V58.- code for aftercare with the V code for amputation status secondary

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    SA Local Chapter
    Thumbs up
    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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