Eli's Rehab Report

Reader Question:

Coding for a Postsurgical Visit

Published on Mon Oct 01, 2001

Question: One of our patients closed her car door on her hand. She went to the urgent-care clinic, received three stitches on her finger, and was told that she fractured her fourth finger. A week later, she came to our office and we ordered her a splint, antibiotics and pain medication, and we removed her stitches. A few days later, she came back because the wound was infected. How should we code for these visits?

Montana Subscriber

Answer: The urgent-care clinic most likely billed for the fracture care and the sutures, but it is your right to code and bill for the services you provided. You should assign the diagnosis code for the fractured finger for the first visit (816.02) along with the V code for the suture removal (V58.3, attention to surgical dressings and sutures). Assign the appropriate code for E/M service.

For the follow-up visit, when the patient had the infection, use an applicable E/M code along with the diagnosis code for postoperative infection, 998.59.

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