Home Health ICD-9/ICD-10 Alert

Question: We are providing aftercare for a neoplasm to a patient who also has hypertension and hypothyroidism. We won't be providing any dressing changes, but the nurse is still assessing for infection. I plan to code V58.42 for this patient, but the V58.4x series includes a note that advises us to use the code in conjunction with other aftercare codes to identify the reason for the aftercare encounter. So, should I also report V58.3 even though the nurse is not physically doing dressing changes, but simply assessing the surgical site? 

 
Washington Subscriber

Answer: The note on the aftercare codes such as the V58.4x codes (Other aftercare following surgery) and the V58.7x codes (Aftercare following surgery to specified body systems, not elsewhere classified ) states: "Codes from this subcategory should be used in conjunction with other aftercare codes to fully identify the reason for the aftercare encounter."

The aftercare codes generally include assessment and teaching. If a dressing change or some other reason for the encounter could add more information to the general aftercare code then add it, but if assessment and teaching are what you are doing, then V58.42 (Aftercare following surgery for neoplasm) is enough to explain.

Unless otherwise indicated, reader questions were answered by Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.