Original Diagnosis and Procedure Codes Are Key to Getting Paid for Rechecks
Published on Mon Nov 01, 1999
Jennifer Bell, practice administrator for Baylor Pediatric Center in Dallas, TX, who always uses the same diagnosis code for the recheck that was used for the original visit. If you put follow-up as a diagnosis, the carrier would say, Follow-up for what? It could be for the ear infection, the gastrointestinal virus, or the upper respiratory infection. I would definitely recommend that people use the original diagnosis code. You could use the V code as a secondary diagnosis, says Bell, but its unlikely to make any difference: The insurance company probably wouldnt look below the primary diagnosis.
However, for the recheck, the pediatricians, for example, write otitis mediaresolved on the notes that are given to the billers, says Bell. There isnt any resolved code, but this way we know to go back to the original otitis media diagnosis.
Charles Scott, MD, FAAP, a regional CPT coding resource physician for the American Academy of Pediatrics, agrees with Bell. I usually use the clinical condition for which the patient first came in when I code a recheck, says Scott, who practices with Medford Pediatric & Adolescent Medicine in Medford, NJ. If the child had otitis media, I would still use that for the follow-up.
While V67.9 (unspecified follow-up examination) may be theoretically accurate, insurance companies dont recognize all the rules, he says. This would be clear-cut if the carriers adhered to all the guidelines.
But even if the insurance companies dont play by the rules, in this case Scott believes there is good rationale for using the original diagnosisbeyond the fact that that is what you will get paid with. Otitis media is the reason for the child coming in, and its the reason for them coming back for a follow-up, he reasons. The plans know theyre paying for a second evaluation. He adds that there are no global fees for this kind of work. In pediatrics, we basically only get compensated for what we do, he says.
Examples of other conditions that call for rechecks include cellulitis, when a doctor wants to see if oral antibiotics are clearing up an infection; corneal abrasion, when the doctor needs to check on healing; pneumonia, when the doctor needs to listen to the lungs; and reactive airway disease, especially in small babies. All of these rechecks would get the original diagnosis code, even if the original problems had cleared up, says Scott.
Hospital Rechecks
The same concepts apply to rechecks done after hospitalizations. If a child is coming to the office for a visit after being hospitalized for something like tastroenteritis or pneumonia and then comes to see you and the condition is resolved, you should use the original diagnosis code, says Richard [...]
