My coworkers and I have been trying to decide which 7th character is appropriate for a follow-up visit where the fracture is totally HEALED, not healing. Everything we look at says healing, not healed. I think it would be a 'D' since it is no longer active, even though 'D' is for a healing fracture, but they are worried that would be incorrect because the fracture is no longer in the healing phase. Any insight from others is much appreciated. Thanks.
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Wiki 7th character for HEALED fracture
- Thread starter nbarthol
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mitchellde
True Blue
If the fracture is documented as healed and requires no further treatment then you code as a follow up.. Z09
kbab98@aol.com
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Healed fractures
How would you code for a healed fracture? The MD states fracture is healed and can be discharged from clinic.
According to coding clinic it states that Z codes should not be used for aftercare involving injuries or poisonings, where 7th characters are provided to identify subsequent care. Routine aftercare and follow-up visits following active treatment of the injury are captured with the 7th character ?D.?
Thank you,
Kim
How would you code for a healed fracture? The MD states fracture is healed and can be discharged from clinic.
According to coding clinic it states that Z codes should not be used for aftercare involving injuries or poisonings, where 7th characters are provided to identify subsequent care. Routine aftercare and follow-up visits following active treatment of the injury are captured with the 7th character ?D.?
Thank you,
Kim
Ash82
Networker
I agree with using Z09. According to the ICD-10-CM general code set training manual,
"The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes, or injury codes with seventh character“D,” that explain ongoing care of a healing condition or its sequelae. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment.
The follow-up code is sequenced first, followed by the history code. A follow-up code may be used to explain repeated visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code."
In the first sentence it says the follow up codes are used to explain continuing surveillance following completed treatment for injury. It does say not to use the Z code if treatment is still ongoing. So, if treatment is complete, Z09, according to AAPC, would be the correct code.
"The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes, or injury codes with seventh character“D,” that explain ongoing care of a healing condition or its sequelae. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment.
The follow-up code is sequenced first, followed by the history code. A follow-up code may be used to explain repeated visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code for the condition should be assigned in place of the follow-up code."
In the first sentence it says the follow up codes are used to explain continuing surveillance following completed treatment for injury. It does say not to use the Z code if treatment is still ongoing. So, if treatment is complete, Z09, according to AAPC, would be the correct code.