How to Code Aftercare for Injuries
Since the implementation of ICD-10, the coding of aftercare for injuries has caused much confusion. First let’s look at exactly when it is appropriate to use an aftercare code. Coding guidelines state, “aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.”
For those of you who were coding back in the ICD-9 days, you may remember that we had a specific aftercare code for injury and trauma. When we moved to ICD-10, one of the very first things that coders realized is that there was not an equivalent code in the new code set. The coding guidelines tell us that “the aftercare Z codes should also not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the appropriate seventh character (for subsequent encounter).”
Why is this the case?
Recovering from a routine planned surgery is very different from recovering from surgery following an accident or injury, and our coding should reflect this.
Despite this guidance, coders are still using aftercare codes for injuries. Let’s look at a scenario to demonstrate the proper way to code aftercare for injuries.
Our patient fell at home resulting in an intertrochanteric fracture of the right femur. After the physicians reviewed the x-rays, it was decided that the best treatment for this fracture would be to replace the hip. After a short stay in the hospital she is being referred to home health for continued PT. How would you code this?
M1021a: S72.141D – Displaced intertrochanteric fracture of right femur, subsequent encounter
M1023b: Z96.641 – Presence of right artificial hip joint
M1023c: W19.XXXD – Unspecified fall, subsequent encounter
As you can see the Z47.1, Aftercare following joint replacement surgery, is NOT used. In this case, you use the actual injury, the intertrochanteric femur fracture with the 7th character of “D”. Remember that “D” as the seventh character indicates a subsequent encounter after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. This accurately describes the care being provided by home health in this case. The Z96 code is added to indicate that the patient has an artificial hip and the W19 code is added to describe the circumstances around the fracture.
When surgeries or procedures are performed as the result of an injury or trauma, look to the coding for the injury first before turning to an aftercare code from chapter 21.