![]() You shouldn't have to change anything with what was previously coded like the dx and cpt codes should stay the same. If I am missing anything here hopefully someone else will come on this thread and add to it but I feel like I covered most if not all what needs to be coded. The code for this is Z91.19 "Patient's noncompliance with other medical treatment and regimen". The final code I feel is needed is one that indicates the patient not adhering to your instructions following surgery. I'm not sure how this encounter would fit the diagnosis considering the circumstances. Do you know anything else about the fall so the code has more specificity as to what caused the fall? If it is not known then I would say the fall was accidental in nature and is not further specified, W19.XXXA if this is the initial encounter, W19.XXXD for subsequent encounter or W19.XXXS if it is a sequela. Your dx code for this would be what was used on the initial claim and the external cause code is the fall. You have to also use any external cause codes which would be the cause of the injury, which would be the fall. The diagnosis codes I know have to relate to the procedure code. The modifiers you would need are for laterality (RT or LT) and a couple of other modifiers I don't know which would be correct but I am thinking if you would describe this as an "increase in procedural services" then you would need modifier 22 and since this sounds like a "repeated procedure or service by same physician or other qualified healthcare professional" you would use modifier 76. I was thinking modifier 78 as well but part of the description for when to use this modifier says within the "postoperative period" which is 10 days and the patient didn't return until after 2 weeks post surgery (14-days). Percutaneous internal fixation of proximal fifth metatarsal Jones fractures, with a Charlotte Carolina screw and bone marrow aspirate concentrate, provides more predictable results while permitting athletes a return to sport at their previous levels of competition, with few complications.Was the procedure open or closed treatment? If you didn't specify open or closed treatment in the procedure note and just specified that it was a nonunion repair of the 5th metatarsal base of the left or right foot then your code would be 28322 with the proper modifiers for laterality in addition to either modifiers 22 and/or 76. One patient experienced a delayed union, and 1 healed but later refractured. Two patients did not return to their previous levels of sporting activity. The mean time to fracture healing on standard radiographs was 5 weeks after surgery (range, 4-24). The mean mental component of the SF-12 score also significantly improved, from 28.20 points preoperatively (range, 14-45) to 58.41 at final follow-up (range, 36-67 P <. The mean physical component of the SF-12 score significantly improved, from 25.69 points preoperatively (range, 6-39) to 54.62 at final follow-up (range, 32-62 P <. The mean Foot and Ankle Outcome Score significantly increased, from 51.15 points preoperatively (range, 14-69) to 90.91 at final follow-up (range, 71-100 P <. Of the 26 fractures, 17 were traditional zone II Jones fractures, and the remaining 9 were zone III proximal diaphyseal fractures. The mean follow-up time was 20.62 months (range, 12-28). All patients were competing at some level of sport and were assessed preoperatively and postoperatively using the Foot and Ankle Outcome Score and SF-12 outcome scores. Percutaneous internal fixation for a proximal fifth metatarsal Jones fracture (zones II and III) was performed on 26 athletic patients (mean age, 27.47 years range, 18-47). To report the results from 26 patients who underwent percutaneous internal fixation with a specialized screw system of a proximal fifth metatarsal Jones fracture (zones II and III) and bone marrow aspirate concentrate. Internal fixation is a popular first-line treatment method for proximal fifth metatarsal Jones fractures in athletes however, nonunions and screw breakage can occur, in part because of nonspecific fixation hardware and poor blood supply.
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