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Question about follow up visits in a family practice

  1. #1
    Default Question about follow up visits in a family practice
    Medical Coding Books
    Hello!

    I am stumped on how to code general follow up vists and would appreciate any assistance please.

    We have a patient who has been seen multiple times for a cough and rales in the past few weeks. Because it is not resolved, would I just continue to use 786.2 for cough? Would I want to use an aftercare code or something like V67.9 (which I thought I couldn't use if the PT still had the the cough and was still being treated for it)?

    Also, is there a code to use for a doctor reviewing the notes of a test done at a hospital or lab work? Or is that just included in the E&M?

    Thank you for your assistance!
    Noelle

  2. #2
    Location
    Hartford, CT
    Posts
    723
    Default
    You code the reason the patient is being seen, so if (s)he's still coming in for the cough and nothing else has been diagnosed you code 786.2. Reviewing of test results is included in the E/M.
    Doreen Clark, CPC, CPMA
    Medical Auditing Specialist
    Integrated Physicians Management Services
    East Harftord. Ct

  3. #3
    Default
    Thank you so much, Doreen, for your response! It is much appreciated! I will do just that. It wouldn't need a modifier, either, if she was seen once on Friday and then once on the following Monday because there is no global period just for an office visit without any surgeries, is that correct?

    Thank you again!
    Noelle

  4. #4
    Location
    New Windsor, New York
    Posts
    1,183
    Default No modifier needed
    That is correct - no modifier would be added - you would just assign the proper E/M code for both the Friday and Monday visits.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

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