Health Information Management

Q&A: Coding for follow-up visit after surgical rod insertion

HIM-HIPAA Insider, February 22, 2011

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Q. A patient presents for a follow-up visit after undergoing surgery for insertion of a rod. The patient’s fracture is healing. Which code is more appropriate, V54.09 (other aftercare involving internal fixation device) or V54.16 (aftercare for healing traumatic fracture of lower leg)?

A. Based on the description of V54.09, I interpret it as the code for denoting scenarios in which the purpose of the encounter is to provide services directly related to the actual internal device (e.g., the rod).
Note that other more specific codes are for “removal” or “adjustment of a growth rod.” These codes suggest the physician does something to the device. Code V54.16 implies the patient is healing and is being seen for the healing fracture itself rather than for a specific adjustment to or removal of the rod or other inserted device.
If the patient was healing and the physician removed or adjusted the rod, both codes may be assigned if the physician documents this information in the record. ICD-9-CM Official Guidelines for Coding and Reporting, p. 72, lend the following support:
Aftercare codes should be used in conjunction with any other aftercare codes or other diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification. The sequencing of multiple aftercare codes is discretionary.
Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA, answered this question in the February issue of Briefings on Coding Compliance Strategies.

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