Eli's Rehab Report

Question: Our physiatrist often takes over the rehabilitation responsibilities for total knee replacement or total hip replacement patients after their surgery. We usually see the patient again for one-year rechecks. How should we code the diagnoses when we perform E/Ms on one-year post joint replacement patients? Should we report V54.81 as the ICD-9 code for these visits?

Florida Subscriber

Answer: Report V54.81 (Aftercare following joint replacement), 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 patients heal at different rates, your patient will likely not require aftercare a full year after her hip replacement, and she certainly wouldn't require aftercare annually.

Your practice more likely performed 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 link V67.09 (Follow-up examination; following other surgery) and either V43.64 (Organ or tissue replaced by other means; hip joint) or V43.65 (Organ or tissue replaced by other means; knee joint) to the E/M code (99211-99215, Office or other outpatient visit for the E/M of an established patient).

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

-- You Be the Coder and Reader Questions were reviewed by Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.