Wiki Need a dx code instead of an E code

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annbishop

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I have a patient who fell at home and hit their head. They were taken to the E/R for evaluation. They had no injuries. They were asked to follow up with their primary care which is the organization I work for. What do we use for a dx code for the follow up visit when the reason for the visit is follow up for fall? The provider coded an E888.9 which we obviously can't use as primary dx.

Thanks.
 
What do you think of:

V67 Follow-up examination
Includes: surveillance only following completed treatment
 
I would use a code from the V71. series. (Observation) These are for use when injury, illness, or signs, and symptoms related to the person's condition are not present and when a person is being observed for a condition that is ruled out. (ie: fracture, stroke, ect)

Follow up codes explain continuing surveillance following completed treatment of a disease or injury. They imply the condition has been fully treated and no longer exist.

History codes explain a patient's past medical condition that no longer exist and is not receiving any treatment, but that has a potential for recurrence and therefore may require monitoring.
 
c422rad said:
I would use a code from the V71. series. (Observation) These are for use when injury, illness, or signs, and symptoms related to the person's condition are not present and when a person is being observed for a condition that is ruled out. (ie: fracture, stroke, ect)

Follow up codes explain continuing surveillance following completed treatment of a disease or injury. They imply the condition has been fully treated and no longer exist.

History codes explain a patient's past medical condition that no longer exist and is not receiving any treatment, but that has a potential for recurrence and therefore may require monitoring.
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I would use the V71.x code also except this was a follow up visit which is why I suggested a history of fall code. Since the patient had already been evaluated and released from the ER and told the patient to follow up with their doctor, I cannot see using the V71.x. However if there were still a question or issue related to the fall and that is the reason for the visit then use that reason.
 
mitchellde said:
I would use the V71.x code also except this was a follow up visit which is why I suggested a history of fall code. Since the patient had already been evaluated and released from the ER and told the patient to follow up with their doctor, I cannot see using the V71.x. However if there were still a question or issue related to the fall and that is the reason for the visit then use that reason.
Click to expand...

My caution to the history code is that, I see this visit as directly related to the fall so I would have a hard time listing it as a ‘history’. At this visit the patient may receive some sort of treatment for his condition…. Such as an adjustment in blood pressure meds, a change in meds, ect. So, I consider this visit an active treatment.

I cannot find anything that say’s the V71.series is only for the initial episode of care so I think it would be okay for a follow-up office visit.
 
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It might be helpful to see what was documented as I can see several different solutions all depending on what the physician examined and determined.
 
thank you all for your suggestions.

Here's what the documentation states

9 month old female presents with mom for F/U. mom states was playing in a child and fell backwards and strike head on floor. She reports infant lost consciousness for 1 minute and was very hard. Denies any convulsions. Was taken to E/R by ambulance and placed in observation. No imaging was done as child was playing and active. Mom reports playful today, not over sleeping, active. no problems. mom reports informed daycare of what happend and they need a note of clearance. Mom reports day care reports all was well and normal today.

physicial exam was all negative

Assement

s/p fall normal exam active toddler atraumatic head exam clearamce letter given for daycare counseled mom on warning signs decrease activity, daytime sleepimness, RTC with any problems
 
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