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professional coding for subsequent post operative visit in an inpatient setting

Shu Zhen Posted Thu 31st of March, 2016 23:09:42 PM

Good evening, Supercoder expert:
The coding question is regarding professional coding in an inpatient hospital setting. An appendicitis patient admitted from 01/01/16 to 01/05/16; Surgeon A performed an appendectomy on the patient on 01/01/16, what is the diagnosis code for the surgeon A's subsequent post operative hospital visits 01/02/16--01/05/16 if the patient did not have any post operative complication or pre-existing condition? According to the ICD-9-CM Official Guidelines for ­Coding and Reporting "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." Should the entire hospital stay 01/01/16--01/05/16 considered an acute phase for the acute appendicitis or just day of surgery 01/01/16 considered acute phase of this illness? and 01/02/16--01/05/16 considered healing or recovery phase, could please answer my question and provide coding resource ASAP, thank you.

SuperCoder Answered Mon 04th of April, 2016 08:00:27 AM

In the above scenario, since the surgeon has performed the appendectomy, the aftercare of the surgery has begun. In other words, if the surgery for the acute illness is performed, and there is no complication arising out of it, the aftercare phase begins, and the acute phase of illness ends. I suggest Z48.815, Encounter for surgical aftercare following surgery on the digestive system, for the surgeon’s subsequent postoperative hospital visits.

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