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Wiki Follow up code and additional diagnosis

wskigirl

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Moore, OK
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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???
 
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.
 
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