Dissection of Aorta
Looking for clarification on coding Dissection of Aorta status post repair. Is there on a general rule on how long a provider scan code for a Dissection of Aorta (I71 code) even after the patient is s/p repair, there have been no complications, and have been having regular follow up visits for general monitoring? Looking for set guidelines on when to switch over to a history of code.
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Hi,
I am unaware of any specific clinical guideline or established timeframe. You may want to review the AHA Coding Clinic for updated coding clarity.
An AAA can be evaluated even after repair depending on the severity of the individual case (i.e. if chronic or residual). Essentially, if the provider is still monitoring, evaluating, assessing, or treating then the I71.- code can be used and coded as an active condition even if post repair. Per the coding guidelines, one can code all conditions that affect decision making and patient care. Best practice is that the provider explicitly document that the dissection is either chronic, residual, or continuing to be monitored to assign an active code or that it is fully repaired/resolved to assign a history code. Since the I71 code is an HCC, one should use caution. A recently repaired AAA may be agreed to clinically, but one that was repaired a year ago without documentation of residual effects on follow-up may not withstand a clinical validation review or RADV audit. If in question, then the CDI specialist or coder should query for clarity.
Thanks,
Jessica