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coding for resolved DX at f/up

Messages
8
Location
Frederick, MD
Best answers
0
Can anyone tell me if a patient comes back for a f/up appointment after receiving treatment and the condition is resovled at the f/up appointment, do you still code for the condition?
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
Can anyone tell me if a patient comes back for a f/up appointment after receiving treatment and the condition is resovled at the f/up appointment, do you still code for the condition?
It will depend.. if it is for an infection and the infection is deemed resolved at this encounter then you use the infection code. For any other condition you use a V67.x code for follow up
 

kewing

Networker
Messages
42
Best answers
0
Follow up

Thank you for that reply. Do you have a resource that I can quote (not to say that your word isn't enough :D)

I'm also struggling with a provider who likes to use "follow up" as the cc for the visit, but without specifying what condition(s) the patient is being followed for. Is it appropriate to use the documented diagnosis then as the cc?

Thanks.
 

kewing

Networker
Messages
42
Best answers
0
Here is the entire note.

Reason for Visit
Follow-Up 1 month follow-up

Diagnoses
CHF (congestive heart failure) [428.0S] - Primary
Hypothyroid [244.9AA]



Progress Notes
Doing well, has been successfully cardioverted and holding NSR currently. Breathing and exercise capacity is improving. Now catheterizing himself twice per day. Discussed whether he can travel. Weight stable. Perfusion study was negative. Found to be hypothyroid on replacement
Exam: vitals stable, blood pressure stable, chest clear,NSR, 1+ edema,no acites resolved.
Imp: CHF, improved, hypothyroidism
Rec: BMP, continue present meds, T4, watch for signs of UTI
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
It looks like a follow up following a cardioversion so I would go to the V67 category and select for followup following other procedure.
 
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