tci E/M Coding Alert - 2013 Issue 10

Reader Question: Diagnosis Matters for Routine Hip Replacement Visit

Question: Which diagnosis code should we report for a patient who comes in for a routine hip replacement follow-up that includes an x-ray?Kansas Subscriber Answer: When a patient presents for an annual follow-up and is symptom-free, you’ll typically report V67.09 (Follow-up examination; following other surgery) and V43.64 (Organ or tissue replaced by other means; joint; hip). Watch out: If the surgeon documents that the patient is still healing from the surgery, you should report code V54.81 (Aftercare following joint replacement) instead. Tip: You should choose an appropriate E/M code (99211-99215, Office or other outpatient...

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