Orthopedic Coding Alert

Answer: Report V54.81 (followed by the V code that identifies the joint replacement site, V43.60-V43.69) only if the patient is still recovering from surgery. Although all patients heal at different rates, your patient likely does not require aftercare a full year after her hip replacement, and she certainly wouldn't require aftercare annually.

Your practice is more likely performing a follow-up examination, during which the physician checks the joint placement, mobility, range of motion and gait. If this is the case, you should assign V67.09 (Follow-up examination following other surgery) and V43.64 (Organ or tissue replaced by other means; hip joint) to the E/M code (99211-99215).

Suppose your patient presented at your practice four months after hip replacement surgery and appeared healthy without obvious surgical complications. Do not automatically select V67.09 or V54.81 without first talking to the patient's orthopedist. The physician is the only person who can decide whether the patient is in the "aftercare" or "follow-up" phase, and she or he should make the final determination.