Health Information Management

Q&A: Codes for healing traumatic finger amputation without an infection diagnosis

HIM-HIPAA Insider, June 5, 2012

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A: ICD-9-CM Official Guidelines for Coding and Reporting indicate four primary circumstances when use of V codes is appropriate. One is reporting aftercare as follows:

A person with a resolving disease or injury, or a chronic, long-term condition requiring continuous care, encounters the healthcare system for specific aftercare of that disease or injury (e.g., dialysis for renal disease; chemotherapy for malignancy; cast change). A diagnosis/symptom code should be used whenever a current, acute, diagnosis is being treated or a sign or symptom is being studied.
 
The same coding guidelines address appropriate use of aftercare codes:
 
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.
 
Now consider the patient with a traumatic finger amputation who presents with an amputation stump and concern about infection at the amputation site. There are no obvious signs and symptoms of infection at the amputation site, and the patient is receiving antibiotics, presumably as a prophylactic measure for infection. In this scenario, aftercare code V54.89 (other orthopedic
aftercare) is the most appropriate ICD-9-CM code for this encounter.
 
The patient’s status is post initial treatment of the traumatic amputation, and the patient is currently in the healing or recovery phase. The physician is not directing current treatment for a current injury. Thus, assigning the 800 code series to indicate a current injury for this encounter is inappropriate.
 
Assigning V54.89 code along with an acute injury code is similarly inappropriate because assigning aftercare codes when treatment is directed at a current injury is inappropriate. Report code V54.89 only. These code sets should not be reported together.
 
Editor’s note: Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS,C-CDIS, CCDS, an independent HIM consultant in Madison,Wis., answered this question, which originally appeared in the April 10 issue of JustCoding.com.



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