Wiki active or subsequent care for pre-ops?

[ksobota]

Our docs do a lot of preop exams for patients. We were told a long time ago when ICD 10 came out that in this instance, say the patient had a fracture that was going to have ORIF, our physicians (internists/fam prac) would use a "D" as the 7th character because they are not providing active treatment for the fracture. Just doing the checks to make sure their chronic conditions will allow them to safely have the surgery performed by an ortho. Just want to make sure this is correct.

We aren't prescribing any pain meds, ordering any xrays for the fracture, or anything for the care of the fracture in particular. We will do EKGs, run CMP, CBC, maybe some other labs depending on the patient some PFTs. I can't remember the lady's exact wording as it's been, what, 6 years now. And I don't know why I'm questioning it now. It seems right to me to use the "D" as we aren't doing any active care for the fracture in particular, even though the fracture itself (under the care of another physician) is actively being treated. I remember the lady teaching our seminar saying something along the lines of, it can be an initial visit to the provider but that doesn't necessarily mean that it's the initial/active treatment for the injury (totally not quoting her). I liken it to a patient may be pregnant but you may be seeing them for a reason completely unrelated to the pregnancy like a cut finger. Not quite the same as the patient is having surgery because of the injury, but again, we aren't treating the injury itself. The guidelines state use the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fx and is receiving routine care for the fx during the healing or recovery phase. Technically, our providers are seeing them in the active phase, but are not providing active care for the fracture.

Would appreciate any input.

 

[thomas7331]

All of the guidance I have seen has been is pretty clear that the diagnosis codes should reflect the phase of treatment that the patient is in at the time of the encounter, not the type of care that the provider is performing. Remember that the guidelines state that "assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists" - with ICD-10 codes, you are reporting the conditions that the patient has, not trying to show what the providers are doing. If your providers are seeing them during the active phase, which is sounds like is the case since the surgery to correct the injury has not yet been performed, then the 7th character 'D' would not be correct since that would indicate that the patient is already in the healing and recovery phase.

If your providers are performing a pre-operative exam, then the actually ARE treating the fracture - they are providing supportive care in coordination with the surgeon, and it is appropriate for them to report the condition as active in the ICD-10 code as it is relevant to the encounter, even if they are primarily addressing the comorbidities.

 

[ksobota]

All of the guidance I have seen has been is pretty clear that the diagnosis codes should reflect the phase of treatment that the patient is in at the time of the encounter, not the type of care that the provider is performing. Remember that the guidelines state that "assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists" - with ICD-10 codes, you are reporting the conditions that the patient has, not trying to show what the providers are doing. If your providers are seeing them during the active phase, which is sounds like is the case since the surgery to correct the injury has not yet been performed, then the 7th character 'D' would not be correct since that would indicate that the patient is already in the healing and recovery phase.

If your providers are performing a pre-operative exam, then the actually ARE treating the fracture - they are providing supportive care in coordination with the surgeon, and it is appropriate for them to report the condition as active in the ICD-10 code as it is relevant to the encounter, even if they are primarily addressing the comorbidities.

Thank you for the reply! I appreciate your advice very much.