October 13, 2016
Our PM&R physician admitted a patient to inpatient rehabilitation from the acute care hospital after having surgery for a traumatic fracture of the right femur for debility and gait training. I found a code for the fracture of the femur S72.91XA or should I use Z47.89 for aftercare? Which code should I use?
You should report S72.91XD for the subsequent care. Since the PM&R doctor is managing the healing phase of the fracture, the 7th character A (active treatment for the condition) is not the correct 7th character. The seventh character D used for encounters after the patient has received active treatment and is now in the healing phase receiving routine care for the condition. The aftercare Z codes should not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, you should assign the acute fracture code with the appropriate 7th character based on the phase of treatment.
In addition you will need to report a secondary diagnosis R53.81 for the debility.
*This response is based on the best information available as of 10/13/16.