EM Coding Alert
Diagnosis Matters for Routine Hip Replacement Visit
Question: Which diagnosis code should we report for a patient who comes in for a routine hip replacement follow-up that includes an x-ray?
Tip: You should choose an appropriate E/M code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) to report the physician’s service.
ICD-10: When your diagnosis system changes in 2014, code V67.09 will become Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm). Code V43.64 will expand into different codes based on right, left, bilateral or unspecified (Z96.64-, Presence of artificial hip joint …). Finally, V54.81 will become Z47.1 (Aftercare following joint replacement surgery).
Kansas Subscriber
Answer: When a patient presents for an annual follow-up and is symptom-free, you’ll typically report V67.09 (Follow-up examination; following other surgery) and V43.64 (Organ or tissue replaced by other means; joint; hip).
Watch out: If the surgeon documents that the patient is still healing from the surgery, you should report code V54.81 (Aftercare following joint replacement) instead.
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