AAPC - Back to school
Results 1 to 8 of 8

Thread: ICD-9 coding for aftercare

  1. #1

    Default ICD-9 coding for aftercare

    AAPC: Back to School
    When having your post-op visit after surgery would you code V58.78 alone or with the surgical Dx in the secondary position.

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    You will not code the condition that required the surgery after the surgery is complete. It is aftercare or followup. Aftercare is when you are still managing some portion of the patients surgical care and the aftercare code should be followed with the code for that care given, such as attention to a device or suture removal, follow up (V67.x) is for a survellience of the patient just to make sure all is going ok. Remember the dx is the patient's so if the condition has be resolved with surgery, do not give it to them again.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3


    I know that I've seen this question answered MANY times. I am trying desperately to find a source for this guideline, as my doctors want to continue to bill the original diagnosis (as the primary) and the aftercare dx as well.

    The guideline from the book was not convincing enough - does anybody have any suggestions?
    Last edited by tammster; 12-07-2010 at 08:14 AM. Reason: typo
    ~Ursula, CPC~

  4. #4
    Join Date
    Apr 2007
    Lubbock, TX


    These ICD-9 conventions are the most applicable:

    For accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-9-CM codes to describe all of these.

    Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (Outpatient, if visit is unrelated to follow-up of resolved condition)

    Previous conditions
    If the physician has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some physicians include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.
    However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. (Inpatient only)

    Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare V code should not be used if treatment is directed at a current, acute disease or injury, the diagnosis code is to be used in these cases. Exceptions to this rule are codes V58.0, Radiotherapy, and V58.1, Chemotherapy. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy or chemotherapy for the treatment of a neoplasm. Should a patient receive both chemotherapy and radiation therapy during the same encounter code V58.0 and V58.1 may be used together on a record with either one being sequenced first.
    Certain aftercare V code categories need a secondary diagnosis code to describe the resolving condition or sequelae, for others, the condition is inherent in the code title.

    The follow-up codes are for use to explain continuing
    surveillance following completed treatment of a disease,
    condition, or injury. They infer that the condition has been
    fully treated and no longer exists. They should not be
    confused with aftercare codes which explain current
    treatment for a healing condition or its sequelae.

    codes may be used in conjunction with history codes to
    provide the full picture of the healed condition and its
    treatment. The follow-up code is sequenced first, followed
    by the history code.
    A follow-up code may be used to explain repeated visits.
    Should a condition be found to have recurred on the follow-
    up visit, then the diagnosis code should be used in place of
    the follow-up code.The follow-up V code categories:
    V24 Postpartum care and evaluation
    V67 Follow-up examination

    Hope that's helpful!

  5. #5


    I know you can use the followup or aftercare codes when patient is discharged from hospital, but what about the day after surgery or the second day after surgery when the patient is still in the hospital, are these V codes applicable then? Or does the dx code for the surgery apply?

  6. #6
    Join Date
    Apr 2007
    Lubbock, TX


    I'd say the aftercare would apply. It's not necessarily for discharged patients, like the previous condition codes - it's for ongoing treatment during the healing period after initial treatment of a disease/injury, to manage the recovery and treat aany side effects that patinet may suffer from - it would be the post-surgical period care. It specifically says that if the initial problem is still being treated after surgery/treatment, the code for the disease/injury would be used instead. It also says that some aftercare V-codes require a secondary diagnosis to describe the resolviing or healing condition, and I'm sure that those have instructions in the tabular section. (But I don't have my book with me).

  7. #7
    Join Date
    Apr 2007
    Columbia, MO


    Even in the inpt setting after surgery you ue the follow up codes for the physician.

    Debra A. Mitchell, MSPH, CPC-H

  8. #8


    Thank you both. The part about "the initial problem still being treated..." in the guidelines is what was confusing me. I really appreciate the timely answers.

Similar Threads

  1. Icd-10 Aftercare codes
    By Lion21@ in forum ICD-10
    Replies: 2
    Last Post: 09-04-2015, 08:54 AM
  2. Coding for Aftercare
    By jennylynh in forum Orthopaedics
    Replies: 12
    Last Post: 06-13-2013, 01:41 PM
  3. Aftercare coding
    By primrose1 in forum Orthopaedics
    Replies: 1
    Last Post: 03-27-2012, 07:49 AM
  4. fx care aftercare codes icd 9
    By Shrina in forum Orthopaedics
    Replies: 1
    Last Post: 09-01-2011, 04:47 PM
  5. Orthopaedic aftercare ICD-9
    By jmgoyette in forum Orthopaedics
    Replies: 4
    Last Post: 07-17-2008, 02:55 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.