Follow up code and additional diagnosis

[wskigirl]

Hypothetically, we are seeing a pt to follow-up for an ear infection. The ear infection is resolved, but patient has another, unrelated, diagnosis at this visit...
do I still code follow up?
or only code the active diagnosis?
Some people believe z09 should also be included. Any thoughts???

 

[danskangel313]

If the ear infection was an acute problem and is now resolved, it's no longer a carried diagnosis. If there is new problem, then that would be the diagnosis coded.