Wiki follow up vcodes

[dsmith06351]

When using the follow up examination V codes, would you include the diagnosis code also? Example the patient comes back for follow up exam for an ear infection, the ear infection is resolved. Would I code 382.00 and the V code or just the V code?

Denise Smith CPC -A

 

[mitchellde]

Lets look at followup first. When a visit is for followup then we do not need any additionsl code to explain why the patient is there , we do not code the condition that originally existed as it is no longer an acute condition or it does not exist. The ear infection however is a bit different. Infections in general, including pneumonia, and UTI, and the otitis media, are conditions that are presumed still present as the reason for the encounter so we would code just the infection code. However if the physician has on a previous encounter cleared the patient but wants them to return for one more check, a true followup, then we use only the V67 code for followup following completed medications.
Debra Mitchell, MSPH, CPC-H

 

[EARREYGUE]

In our office our doctors write resolved or resolving when they come in for the follow ups.We code only the V67 when they write resolved, however if they write resolving, to us that indicates the infection is still there, so we do the v67 as primary and secondary the infection.

 

[skillingbeck]

In this instance, I would give the V67 for the followup and then add a 2nd Dx of V12.49 because the patient no longer has the ear infection.