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Diagnosis Coding Guidelines for Aftercare

Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. Post-op care is different from aftercare. Post-op care falls into this category of care when the condition that precipitated the surgery no longer exists, but the patient still requires therapy care to return to a healthy level of function. Diagnosis coding guidelines for aftercare are mentioned along with suitable clinical examples in this article. 

Aftercare Diagnosis Coding Guidelines

ICD-10 makes two important points about the use of aftercare codes: 

  1. The aftercare Z code should not be used if treatment is directed at a current, acute disease.
    1. The aftercare Z code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases. Exceptions to this rule are codes Z51.0, Encounter for antineoplastic radiation therapy, and codes from subcategory Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy, chemotherapy, or immunotherapy for the treatment of a neoplasm. If the reason for the encounter is more than one type of antineoplastic therapy, code Z51.0 and a code from subcategory Z51.1 may be assigned together, in which case one of these codes would be reported as a secondary diagnosis.
  2. The aftercare Z codes should also not be used for aftercare for injuries. 
    1. Aftercare for injuries during the healing and recovery phase should be coded with the injury code and the appropriate 7th character for subsequent encounters rather than a Z code. An example would be aftercare for an unspecified fracture of the lower end of the right humerus. Because the patient is returning for treatment during the healing and recovery phase, the diagnosis code for the injury S42.401 would have the 7th character of ‘D’ to indicate the encounter is a subsequent encounter for aftercare with routine healing. Additional subsequent encounter 7th characters are available to describe delayed healing, non-union, or malunion. This diagnosis code with the correct 7th character would be first listed. 
  3. The aftercare codes are generally first listed to explain the specific reason for the encounter. An aftercare code may be used as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable. An example of this would be the closure of a colostomy during an encounter for treatment of another condition.
  4. Aftercare codes should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit unless otherwise directed by the classification. The sequencing of multiple aftercare codes depends on the circumstances of the encounter.
  5. Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae. For others, the condition is included in the code title. Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings.
  6. Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare. For example, code Z95.1, Presence of aortocoronary bypass graft, may be used with code Z48.812, Encounter for surgical aftercare following surgery on the circulatory system, to indicate the surgery for which the aftercare is being performed. 
  7. A status code should not be used when the aftercare code indicates the type of status, such as using Z43.0, Encounter for attention to tracheostomy, with Z93.0, Tracheostomy status.

Aftercare vs. Follow-up Codes

Follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes that explain current treatment for a healing condition or its sequelae represented with the 7th character for subsequent encounters. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code. A follow-up code may be used to explain repeated visits. When a condition has recurred on the follow-up visit, assign the diagnosis code in place of the follow-up code. An example would be a follow-up visit for a patient after completing a regime of IV antibiotics for recurrent pneumonia; now resolved. Z09 for follow-up not related to malignant neoplasm is sequenced first followed by the history of (recurrent) pneumonia, Z87.01, to describe the condition now resolved.

We hope these diagnosis coding guidelines for aftercare will help you to accurately choose diagnosis codes. In case of any assistance required in diagnosis and/or procedural coding and overall medical billing services, contact us at info@ medicalbillersandcoders.com/ 888-357-3226 

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