Wiki postoperative visit diagnosis

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Bernadette10

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Outpatient postop clinic visit - Would I just code Z48.89 encounter for other specified aftercare since this note doesn't state what the previous surgery was? Or since I had to check when the surgery was done to verify the global period anyway, can I look at the operative note to see that she had a lap cholecystectomy and code Z48.815 aftercare following surgery on digestive system? I can't find a reference saying that each note needs to stand alone. The only thing I'm finding is the 1995/1997 doc guidelines that say there must be a chief complaint, and I did find this link about which parts of the medical record coders can use, but it doesn't help with this question http://www.hcpro.com/HOM-209034-5728/Understand-which-parts-of-the-medical-record-coders-can-use.html

"Patient returns for postop evaluation. She continues to have severe abdominal pain, severe nausea and diarrhea. Her appetite is slightly better, and she has eaten more than at the last time I saw her. Denies fever or chills. Pain is worse with movement.
On exam she appears malnourished. Abdomen is soft but tender to palpation, right greater than left.
Will send cholestyramine and Zofran. CT scan to evaluate for abscess."

Similar question - If a patient comes in for postop visit after a partial toe amputation, but the brief note only says "here for postop follow up, doing well, debrided, discharged," can I look at the previous Op note and see that he had the partial toe amputation and code Z47.81, Z89.422 ortho aftercare following amputation and absence of toe, or Z47.89 orthopedic aftercare, or should I only code Z48.89 other specified aftercare since that's all this note says? I'm not sure what I'm allowed to use. Thanks.
 
Since all coding is based on what is occurring at an encounter and not for an entire patient history, your codes have to be supported by the documentation of that same encounter - you cannot assume that a particular diagnosis is present or relevant to the encounter without physician documentation. Coding Clinic and other specialty publications have addressed this - for an example, see the section titled 'physician queries and the use of prior information' on page 10-11 of the article at the link below, which quotes Coding Clinic's guidance that "if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation."

 
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