Archive for February, 2016

February 14, 2016

Joint Replacement or Fracture: “Breaking” News

New “guidance” has been received that is contrary to current practice. Unlike the guidance regarding choosing A vs choosing D for an injury or complication, which was issued via the quarterly published Coding Clinic, this guidance was issued in a letter to an individual in response to a specific question. First, it’s important to note that a letter response to an individual’s question is not considered “official” guidance.

Also, following this guidance is a huge shift in thinking, therefore the Board of Medical Specialty Coding and Compliance (BMSC) is working with the Coding Clinic to obtain official guidance on the issue prior to widespread education and changes to the HCS-D exam. I recommend waiting until official guidance is released prior to changing practices.

Some background:

BMSC board members and other coding ‘gurus’ have been discussing the issue for months. The issue: Considering the guideline to not code aftercare for injuries, and the excludes 1 note at Z47, should we be coding the fracture itself when repaired by a joint replacement, rather than the Z47.1 code for aftercare following the joint replacement? Here’s the guideline:

The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).

There is also this guideline:

If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis. For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the first-listed or principal diagnosis.

ICD-9-CM guidance indicated that when a fracture was repaired by a joint replacement, that the aftercare code for the joint replacement was the better choice. Of course, in ICD-9 we coded aftercare for ALL fractures. This newest Coding Clinic letter indicates that the appropriate code for a trauma fracture repaired by a joint replacement is the fracture code with a 7th character of D. This response does not make clinical sense (i.e., the fracture is gone) and opens up many other questions regarding other situations and even the use of Z47.3-.

What now:

To repeat, BMSC is working with the Coding Clinic to obtain official guidance on the issue prior to widespread education and changes to the HCS-D exam. I recommend waiting until official guidance is released prior to changing practices.