![]() ![]() Adding the additional codes like the external cause and the factors influencing health status and contact with health services codes are needed to further support the procedure code and the modifiers given. You shouldn't have to change anything with what was previously coded like the dx and cpt codes should stay the same. If I am missing anything here hopefully someone else will come on this thread and add to it but I feel like I covered most if not all what needs to be coded. The code for this is Z91.19 "Patient's noncompliance with other medical treatment and regimen". The final code I feel is needed is one that indicates the patient not adhering to your instructions following surgery. ![]() I'm not sure how this encounter would fit the diagnosis considering the circumstances. Do you know anything else about the fall so the code has more specificity as to what caused the fall? If it is not known then I would say the fall was accidental in nature and is not further specified, W19.XXXA if this is the initial encounter, W19.XXXD for subsequent encounter or W19.XXXS if it is a sequela. Your dx code for this would be what was used on the initial claim and the external cause code is the fall. You have to also use any external cause codes which would be the cause of the injury, which would be the fall. The diagnosis codes I know have to relate to the procedure code. The modifiers you would need are for laterality (RT or LT) and a couple of other modifiers I don't know which would be correct but I am thinking if you would describe this as an "increase in procedural services" then you would need modifier 22 and since this sounds like a "repeated procedure or service by same physician or other qualified healthcare professional" you would use modifier 76. I was thinking modifier 78 as well but part of the description for when to use this modifier says within the "postoperative period" which is 10 days and the patient didn't return until after 2 weeks post surgery (14-days). Because the fracture is also fixed by the dislocation fixation, separate reporting may not be indicated.Was the procedure open or closed treatment? If you didn't specify open or closed treatment in the procedure note and just specified that it was a nonunion repair of the 5th metatarsal base of the left or right foot then your code would be 28322 with the proper modifiers for laterality in addition to either modifiers 22 and/or 76.
0 Comments
Leave a Reply. |
Details
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |