Scenario: Lumbar stenosis, decompression surgery

A 65-year-old man has severe lumbar stenosis and recently underwent decompression surgery to ease the symptoms of the disease. Following his hospital stay, he was admitted to home health to continue his recovery. Surgical aftercare is the focus of the admission, along with physical therapy for strengthening and pain management. He also has COPD, which is stable, and has had both knees and his left hip replaced, all due to osteoarthritis. He still has osteoarthritis in his right hip.

Code the scenario:

Rationale:

• There is no unique code for surgical aftercare on the musculoskeletal system. Z47.89 is the best possible choice to capture the patient’s surgical aftercare.
• Your patient’s musculoskeletal system surgery wasn’t required due to an injury, so it’s appropriate to list an aftercare code. If the patient’s surgery was in response to an injury, an aftercare code would not be appropriate.
• The surgery treats but does not resolve lumbar stenosis, so you’ll still code for this condition.
• The patient has osteoarthritis in one hip. The Coding Clinic has said that primary osteoarthritis is the default. So you should code for unilateral primary osteoarthritis in the right hip as an active diagnosis.
• Don’t code for osteoarthritis in his knees and left hip because it was resolved by the joint replacements.
• Z9.642 and Z96.653 capture the presence of two knee and one hip replacements.
• COPD has the potential to impact his recovery, so you should code for it. It’s described as stable, so it’s sequenced lower on the list than the orthopedic diagnoses.