AHA Coding Clinic® for ICD-9 - 2009 Issue 1; Ask the Editor

Follow-up Visit for Healed Fracture

The patient is an 18-year-old male who had previously sustained a comminuted right distal tibial fracture that had been treated with open reduction and internal fixation, using wire and screws. The patient was doing well and is now being seen in the physician’s office for follow-up x-rays. The x-ray demonstrated that there had been no backing out of the screws with complete union of all fracture fragments. The provider noted, “Complete alignment and union of fracture with full range of motion. Patient is pain-free and can return to his previous sports activities without limitations.” Is code V54.09, Other aftercare involving internal fixation device, or code V54.16, Aftercare for healing traumatic fracture of lower leg, assigned for this encounter. ...

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