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