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Postoperative Diagnosis

  1. #1
    Default Postoperative Diagnosis
    Medical Coding Books
    I am having trouble trying to find a postoperative diagnosis.

    The general surgeon doesn't give me any other diagnosis to use other than Post op from laparoscopic cholecystectomy.

    On another note he only gives me a diagnosis of status post mastectomy postop day #1.

    Can someone help me find these codes? I found a V code, but the V code cannot be used as the primary diagnosis.

    Thank you!
    Tiffany Fischer, CPC, CEMC

  2. Default Post Op Dx
    If it is a post op visit it is a no charge visit so you can report the V code if that is only only dx you have as post op visits are for reporting purposes and not payable and ususally/should have a zero charge.
    Hope this helps.

  3. #3
    Columbia, MO
    It is either a V code for follow up or a V code for aftercare and eiter are appropriate for first listed codes regardless of wether the visit is within the global and a no charge or outside the global and billable.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Casa Grande
    Along this line. . . a family physician is seeing a patient in the office following a cholecystectomy performed by another physician. He lists "s/p cholecystectomy, RUQ abdominal pain and GERD".

    The V58.75 states to code to use "other aftercare codes to fully identify the reason for the aftercare encounter". Does this apply only to the surgeon performing the surgery? I could not find another aftercare code, only the initial problem 574.20. Is it appropriate to use 574.20 as 2nd?

    I'm new to family physician coding...not sure of the rules for coding after other surgeons do surgery.

    Thank You!

  5. #5
    Columbia, MO
    no it is not apporpriate to use the preop dx as a secondary dx. If there is no aftercare being rendered the you need a V67.xx code for follow up. The V58.75 needs another V code to specify the type of aftercare being rendered such as V58.32 for suture removal, or a V53.x or V52.x for attention to a device.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Casa Grande
    Sorry for the delay in saying thanks!!!! Thank You!!!!

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