Outpatient Facility Coding Alert

Question: A patient had an open reduction internal fixation (ORIF) hip surgery and returned for an MRI due to pain one week later. The physician states “status post ORIF” in the indication with no significant findings in the impression. Should this be written off as a comparison exam?

Illinois Subscriber

Answer: This encounter does not classify as a comparison imaging study. Comparison imaging typically refers to a provider imaging a contralateral limb or organ. In the example provided, the documentation only allows for you to bill the follow up exam as aftercare. However, if there is documentation to support that the patient is experiencing pain following the surgery, the provider should document as much in the indication.

If the provider leaves the indication as is, then you should report an aftercare Z code for the follow-up imaging. In the ICD-10-CM index, you will find Aftercare ⇒ following surgery (for) (on) ⇒ orthopedic NEC leads you to report code Z47.89 (Encounter for other orthopedic aftercare). However, the coding crosswalk for code » 73721 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material) does not reveal code Z47.89 as a reimbursable diagnosis. You should check your state’s Local Coverage Determinations (LCDs) to confirm.

If your provider is able to addend the indication to state that the patient is experiencing hip pain following an ORIF, you’ll have to consider the ICD-10-CM guidelines before determining the correct code. The 2019 ICD-10-CM guidelines instruct you to report a postoperative pain code from Category G when the pain is related to a postoperative complication. Assuming the provider does not document a postoperative complication that can account for the patient’s pain, you should abide by the following guidelines in Section 1.C.6.b:

• “Postoperative pain not associated with a specific postoperative complication is assigned to the appropriate postoperative pain code in category G89 (Pain, not elsewhere classified).”

However, before reporting a code under category G89, consider this additional guideline:

• “Routine or expected postoperative pain immediately after surgery should not be coded.”

This means that, assuming there is no documentation of a specific postsurgical complication in the impression, you will have to rely on code G89.18 (Other acute postprocedural pain) for a diagnosis of pain following an ORIF procedure. This diagnosis is also not listed under the ICD-10-CM coding crosswalk for code 73721. Assuming you’ve confirmed with your state’s LCDs, you may not be eligible to receive reimbursement for this imaging service regardless of the diagnosis you report.

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