Wiki Recurring Periodic F/U visits for Resolved Conditions

[baroquecoder]

chief complaint; follow-up.

Can a cardiologist continue to report a resolved I48.91 at every subsequent visit, complete with EKG of course, even though patient is asymptomatic?

How about the extent to which they can report CAD I25.10 whereby the patient was treated and is asymptomatic now?

 

[thomas7331]

Whether or not the patient is symptomatic is not really relevant to the coding - a disease may be present even if the patient does not have symptoms, so I would rely on the provider's assessment rather than the presence or absence of symptoms.

But for resolved conditions, as I understand it, if a provider sees a patient to follow up on an active problem, and documents making the assessment in that particular encounter that a condition is now resolved, then it can be coded with the disease code since that was still the reason for the visit. But going forward, for any future encounters, that condition should be coded as history, and not with the active code.