The patient had a heart transplant several years ago and now presents for an annual heart evaluation. There are no acute issues on presentation. How should this encounter be coded?
Assign code V58.44, Aftercare following organ transplant, as the reason for the encounter. As published in Coding Clinic Fourth Quarter 2004, page 101, code V58.44 is intended for patients who receive an organ transplant and are seen on a routine basis to assess the functioning of the new organ. This information supersedes Third Quarter 2003, page 16. Please note that an additional transplant status code (V42.0-V42.9, in this case, V42.1) may be used with code V58.44 to provide additional information regarding the specific organ transplanted. Follow-up codes are not appropriate here because treatment has not been completed. The patient will always be maintained on immunosuppressive therapy and therefore will require ongoing monitoring.