Wiki Hospital follow ups

[britbrit852003]

I am trying to figure out the correct way to code hospital follow ups.
For example patient seen in hospital for GI bleed it gets treated and now he no longer has it. A few days later he follows up with his PCP (our docotors) for this issue. Would it be history of GI bleed or active?
There are different thoughts on this here: one is code as active since its the first follow up from that active condition and the first time our doctor has seen patient for it; and other is code history since the intent of history codes means no longer exists and no treatment being done and thats the case here.

 

[ak0011]

Follow up

I am trying to figure out the correct way to code hospital follow ups.
For example patient seen in hospital for GI bleed it gets treated and now he no longer has it. A few days later he follows up with his PCP (our docotors) for this issue. Would it be history of GI bleed or active?
There are different thoughts on this here: one is code as active since its the first follow up from that active condition and the first time our doctor has seen patient for it; and other is code history since the intent of history codes means no longer exists and no treatment being done and thats the case here.

Since the problem no longer exists it would not be correct to code it as active regardless of it being the first time for your docs. You should code this as a follow up or aftercare code depending on the circumstances.
If the condition was "FULLY" treated and no longer exists then the follow up codes should be used. If the condition required continued care during the healing phase then the Aftercare codes should be used.
In either case I would follow the initial code with a history code to help paint the picture. However if there were any new or continued signs or symptoms you would code for those in place of the aftercare or follow up codes.

Hope this helps