# Diagnosis Documentation



## nlbonn (Sep 21, 2018)

Hi Everyone! I'm new at the whole auditing portion, so bear with me, please! 

Patient is 5 months post-op odontoid screw placement, no new issues. Chief complaint says postop visit and followup for odontoid screw. The doctor doesn't state "reason for visit" or any "diagnosis". Throughout the note he mentions the odontoid screw, use of a cervical collar, but that's it. This visit he states the patient is making a satisfactory recovery, and releases to followup only as needed. Would you suggest using Z98.1, or ask the doc for a diagnosis?

Thanks in advance!
Nic


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## Evelyn Kim (Oct 2, 2018)

nlpurvis said:


> Hi Everyone! I'm new at the whole auditing portion, so bear with me, please!
> 
> Patient is 5 months post-op odontoid screw placement, no new issues. Chief complaint says postop visit and followup for odontoid screw. The doctor doesn't state "reason for visit" or any "diagnosis". Throughout the note he mentions the odontoid screw, use of a cervical collar, but that's it. This visit he states the patient is making a satisfactory recovery, and releases to followup only as needed. Would you suggest using Z98.1, or ask the doc for a diagnosis?
> 
> ...



The patient is out of the post-op period so the Z98.1 can not be a first listed DX.  Z89.890 (other specified posprocedural states) followed by Z98.1 would be my recommendation since the visit is billable.


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## TThivierge (Oct 4, 2018)

*Odontid neck fracture aftercare*



nlpurvis said:


> Hi Everyone! I'm new at the whole auditing portion, so bear with me, please!
> 
> Patient is 5 months post-op odontoid screw placement, no new issues. Chief complaint says postop visit and followup for odontoid screw. The doctor doesn't state "reason for visit" or any "diagnosis". Throughout the note he mentions the odontoid screw, use of a cervical collar, but that's it. This visit he states the patient is making a satisfactory recovery, and releases to followup only as needed. Would you suggest using Z98.1, or ask the doc for a diagnosis?
> 
> ...



Hi N
I would put the dx first S12.8XXD Fracture neck odontid(bone in neck) showing still healing routine care on neck fracture, then I would next put the Z47.8 code for aftercare. These 2 dx. codes will help . The dx Z47.8 is not a first listed dx code.

Lady T


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## kdlberg (Oct 11, 2018)

TThivierge said:


> Hi N
> I would put the dx first S12.8XXD Fracture neck odontid(bone in neck) showing still healing routine care on neck fracture, then I would next put the Z47.8 code for aftercare. These 2 dx. codes will help . The dx Z47.8 is not a first listed dx code.
> 
> Lady T



I would also put the S12.8xxD. I'm not entirely sure you would _need_ the Z code, because the injury itself demonstrates the medical necessity for the visit.


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## ndanh01 (Oct 11, 2018)

I would use the Z-codes because the provider did not state in the documentation that there is a fracture.  Even though we know there is a fracture, we can only abstract what is on the document.  In this case I would not use the S-code, I would use a Z-code for the follow up because the provider states postop visit and followup for odontoid screw.


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## nlbonn (Oct 26, 2018)

Thank you all for your perspectives!


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