Question

This 78-year-old male is status post hip replacement 6 days ago. He is now at the Sunny Hill Rehabilitation Center, where we are currently working on physical and occupational therapy so that he will be able to live at home and function normally. This patient is working on being able to groom and dress himself. He is very anxious to able to use the shower but would be unable to get into his tub unassisted. Today we worked on walking to the closet/dresser, walking back to the bed, and getting his clothes on unassisted. He did very well, though he tired easily, and we did not get to the bathroom to brush teeth or wash up. The assessment took 60 minutes. ICD-10-PCS Code

Answer 1

2020 ICD-10-CM Diagnosis Code Z47.1 (Aftercare following joint replacement surgery) is the appropriate code as per guidelines though we have another code 2020 ICD-10-CM Diagnosis Code Z47.32 (Aftercare following explantation of hip joint prosthesis).

Reason: As per guidelines, if the condition for which the rehabilitation service is being provided is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis, unless the rehabilitation service is being provided following an injury. Also an example given in guidelines "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".

Thanks!