Personal History Diagnosis

[debnance2@icloud.com]

I am a newbie and would appreciate some weigh in here. We saw a patient today and my physician used cancer of the larynx for his diagnosis. I took it to him and explained that we have coded it as personal history in the past and asked if the cancer had returned, no it has not, Okay, fairly straightforward. Will code as personal history. However, that started the discussion about deviated septum, effusion and chronic sinusitis. He states that he uses septal deviation, although we have just repaired it when patient returns for follow up visits. Similarly with effusion, if we have placed a tube we cannot test it so he continues to use eustachian tube dysfunction when patient is seen in follow. And, again, with our sinus cases when they return for follow-up status post surgery (outside global for all of these examples, naturally) he still uses chronic sinusitis.

What is the appropriate ICD9 to use in these cases - i.e. where surgery has resolved the issue but patient returns in follow up?

 

[mitchellde]

When the condition has resolved and no further care is needed you use the follow up V codes(V67.-), if there is still aftercare services such as dressing changes the you use the appropriate aftercare V code. It is incorrect and inappropriate to assign a dx code to the patient for a diagnosis that is no longer present. Check you guidelines for confirmation of this information.