Wiki Follow Up visit for Lumbar disc herniation S/P microdiscectomy

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FractalMind

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Hello there!

My question is: if the lumbar disc herniation was repaired a few days ago and the patient is still in the healing/recovery phase, do we still code M51.16 or do we report the history code?

Physician reported diagnoses Z48.811 & M51.16 for this post-op visit S/P lumbar microdiscectomy.
Encounter date: 4/5/24
70 year old female s/p left lumbar 1.2/3 hemilaminectomy and durotomy repair on 3/28/24 who presents with leg pain which is most likely postoperative pain that will resolve with time; however, I will order outpatient MRI to assess for any postop changes. Wound evaluated, CDI. Post-op wound care instructions advised and given to patient. Continue routine health care management with Primary Care Doctor for non-surgical proactive care management.

Diagnoses reported by neurosurgeon: Z48.811, M51.16.
 
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FractalMind said:
Hello there!

My question is: if the lumbar disc herniation was repaired a few days ago and the patient is still in the healing/recovery phase, do we still code M51.16 or do we report the history code?

Physician reported diagnoses Z48.811 & M51.16 for this post-op visit S/P lumbar microdiscectomy.
Encounter date: 4/5/24
70 year old female s/p left lumbar 1.2/3 hemilaminectomy and durotomy repair on 3/28/24 who presents with leg pain which is most likely postoperative pain that will resolve with time; however, I will order outpatient MRI to assess for any postop changes. Wound evaluated, CDI. Post-op wound care instructions advised and given to patient. Continue routine health care management with Primary Care Doctor for non-surgical proactive care management.

Diagnoses reported by neurosurgeon: Z48.811, M51.16.
Click to expand...
Untill the postop follow up duration we can consider the condition as active and post which when the treatment plan is completely stopped should be coded with History
 
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Check your official ICD-10 Guidelines. See 21. Factors influencing health status and contact with health services, 7) Aftercare.
There is no M51.16 because the patient had a microdiscectomy. Unless they still have an intervertebral disc disorder with radiculopathy, lumbar.
You also would not do as suggested above with Z98.1, there is no indication the patient had a fusion in your example.

If there is postop pain that is severe or abnormal, you could also look at the G pain codes for postprocedural pain, etc. However, the documentation would have to specifically state this.
If it was an injury like a fracture for example, you would continue to report the S code with the proper 7th character (like D if it is subsequent routine healing).
 
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Arthrodesis (Fusion)

In this process, any diseased cartilage between the two bones is removed, the bone ends are cut off, and the two bone ends are connected to one another using metal internal fixation, such as screws and plates. The two bones eventually grow into one another, fusing to become one.
 
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