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Primary Care Coding Alert

Reader Question:

Report V Codes for Patient's Long-Term Meds

Published on Mon Oct 15, 2007

 Question: A new patient reported to the FP and received a level-two E/M service. The patient file indicates that she is here due to effects from long-term current use of aspirin and steroids. How should I report the encounter if I want to note the steroid and aspirin use in the medical record?

Michigan Subscriber


 Answer: You should report a pair of V codes in addition to the E/M code:
 - report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) for the E/M.
 - attach V58.65 (Long-term [current] use of steroids) to 99202 to represent the patient's steroid use.
 - attach V58.66 (Long-term [current] use of aspirin) to 99202 to represent the patient's aspirin use.
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