Health Information Management

Q&A: Coding for healing traumatic finger amputation

JustCoding News: Inpatient, April 11, 2012

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QUESTION: For a healing traumatic finger amputation with concern but no diagnosis of infection at the amputation site (the physician prescribed Bactrim), is it correct to assign code V54.89 (other orthopedic aftercare) and ICD-9-CM code 886.x (traumatic amputation of finger)?

ANSWER: According to ICD-9-CM Official Guidelines for Coding and Reporting, there are four primary circumstances when it is appropriate to use V codes. One of them includes reporting aftercare as follows:

A person with a resolving disease or injury, or a chronic, long-term condition requiring continuous care, encounters the health care 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.

These same official coding guidelines provide guidance on the appropriate use of aftercare codes, stating:

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 let's consider the patient with a traumatic finger amputation who presents with an amputation stump and concern for 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 prophylatic measure for infection. In this case, the aftercare code V54.89 (other orthopedic aftercare) is the most appropriate ICD-9-CM code to report for this encounter in light of the coding guideline cited above.

The patient’s status is post initial treatment of the traumatic amputation, and he or she is currently in the "healing" or "recovery" phase. The physician is not directing the current treatment toward a current injury. Thus, it’s inappropriate to assign the 800 code series to indicate a current injury for this encounter. Likewise, it’s inappropriate to assign the V54.89 code along with an acute injury code, given the fact that aftercare codes are not to be assigned when treatment is directed at the current injury. Therefore, report only code V54.89.

By definition 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 revenue cycle consultant based out of Madison, WI, answered this question.

This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to Senior Managing Editor Andrea Kraynak, CPC, and we’ll do our best to get an answer for you.

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