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Aftercare fx code or acute fx code

  1. Default Aftercare fx code or acute fx code
    Medical Coding Books
    PT here for f/up of ORIF RIGHT subtroch hip fracture treated in outside the USA 3/2/10. She fell while disembarking from a van onto a cobblestone surface. While hospitalized she sustained a sacral decubitus ulcer. She recently returned to her home here on 3/15/10. She is here for f/up care.
    She has little pain. She is not taking pain medication. Ambulation with walker is difficult and patient requests wheelchair.

    Marked sacral erythema. Large decubitus. Foul smelling. Dressing applied in outsied the USA
    Hip wounds and knee wounds well healed without evidence of infection.

    Subtroch RIGHT hip fx with reverse obliquity txed with locked IM nail. Fx is somewhat displaced/distracted?

    S/P ORIF RIGHT subtroch fx; treatment Outside the USA.
    Sacral decubitus.
    TTWB with walker
    Physical therapy for transfers, etc.
    Gen surgery to see today for decubitus management.
    F/up one month with new xray of hip.
    Discussed the possiblity of non-union.

    Should we use the Aftercare code for her first vist to the dr. in the US or the acute fx code.

  2. #2
    Columbia, MO
    You would not use the acute fx code for this document it would be the V code for healing fx, that is since we cannot code the possible non union. If at some point the physician does document a non union then you can code for that.

    Debra A. Mitchell, MSPH, CPC-H

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