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Diagnosis code for a follow-up visit

  1. Default Diagnosis code for a follow-up visit
    Medical Coding Books
    If a patient comes in for follow-up on bronchitis and physician states "bronchitis resolved", what ICD-9 diagnosis code would you use? Should it be V67.59 and 490?


  2. #2
    Default diagnosis
    Follow up visits with resolved conditions are still coded with the same ICD-9 code as the first visit. See the link below.

  3. Default Both
    I use a V code and the the original Dx. So yes, both. I did not check the accuracy of your codes in particular, I just want to let you know that I use both a V and a Dx code.

  4. #4
    Yes we also use the V code and the original DX code if documentation states resolved. The key here is resolved vs resolving.

  5. #5
    Overland Park, KS
    I disagree! If the diagnosis is resolved, you can't code it. You would report the appropriate V code for the follow-up (from the V67 category), then as a secondary code, you would report a V code for history of the condition that you are following up for. This is per the ICD-9-CM guidelines.
    Last edited by dballard2004; 05-12-2010 at 05:50 AM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  6. #6
    Milwaukee WI
    Default Follow-up
    The physician doesn't know the condition is resolved until s/he evaluates the patient. Code the condition (bronchitis in your example).

    Once patient has completed treatment for the condition and the physician is no longer treating it, if the patient comes back with similar symptoms you can code the "history of" (assuming the physician documents it, of course).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Columbia, MO
    I am a little confused by the scenario. If the condition was known to be resolved prior to this encounter then I agree with Dawson. However if this was a visit to check the patients condition, then that is different. Infections/inflamations we assume are still present and that is the reason for the encounter so I agree with Tessa the physician must examine to pt first and renders the dx of resolved so we code the condition. Never code both the V code for follow up plus the condition.

    Debra A. Mitchell, MSPH, CPC-H

  8. #8
    Another scenario; If the physcian sees a patient in the hospital for ARF,(say from NSAIDS or a rise in creatinine due to contrast reaction). The ARF is resolved when discharged from the hospital, but the physician wants to F/U with him in a couple of weeks. At the visit, all labs are normal. Would you code the ARF?

    Very confusing:

  9. #9
    Columbia, MO
    No you would code it as a follow up with a V67.x

    Debra A. Mitchell, MSPH, CPC-H

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