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Dx Resolved - this basic question but we have a physician

  1. #11
    Location
    Greeley, Colorado
    Posts
    2,045
    Red face
    Medical Coding Books
    Quote Originally Posted by kevbshields View Post
    Actually, the specific purpose of the follow up would need to be clearly stated in that record.

    Coding symptoms and conditions that have resolved (outside using "history of") is inappropriate and misrepresentative--per the official, government-accepted ICD guidelines.

    Sometimes as coders it's our duty to improve practices that are out of date or questionably compliant. That may involve re-educating our providers or creating a documentation improvement program. It may also involve more creative, but nonetheless compliant ways of dealing with documentation issues.

    In the meantime, I wish everyone luck and encourage them to consider how the payer will review the record and claim against one another. That should help to set policy.

    Can you point me in that direction then Kevin? Because I am apparently doing it wrong. My question then is, how many payers will pay for a V code with a problem oriented E/M?

  2. #12
    Default
    I always thought that if the patient was seen for abdominal pain, doctor recommends treatment, and then wants to see patient back in two weeks that abdominal pain for the two week followup would be appropriate to code because that is the whole reason for the followup. The doctor wanted to see them back to see if the treatment worked. It is great that it has resolved but it is the reason the patient is there.

    I guess this is just one of those "grey" areas that we all have to deal with on a daily basis.
    Susie Corrado, CPC
    __________________
    ENT Coding/Billing

  3. Default
    I guess I was under the same impression as Susie. I thought I was able to use abdominal pain for the follow up visit. Even though the pain has resolved, it was still being addressed at this visit. I'll need to re-think this one.

    ~L
    CPC, CGSC, COSC

  4. #14
    Default Resolved Conditions
    If a patient is being seen for a follow up for thrush, and the patient's thrush has resolved, no other condition being treated that day, would you use V67.59?
    Heather Winters, CPC, CFPC

  5. #15
    Location
    Stratford, NJ
    Posts
    39
    Red face INITIAL ER visit
    Remember what F Tessa just posted....P Forster says these are INITIAL Er visits. There is no follow up here.

    P Forster, I think we need to know why the pt had an ER visit. Did the pt come to the ER w/abdominal pain, but by the time the Dr came in to see the pt, it had resolved?? Or did the pt come to the ER for what he may have considered a "precautionary" visit because he had abd pain earlier?? It seems unneccesary to go to the ER when your pain is gone, unless maybe pt's a female who may be afraid of ectopic, etc...?
    How did you end up coding it, anyway?

  6. #16
    Location
    Louisville, KY
    Posts
    1,101
    Default
    Apologies, I wasn't aware this thread was getting attention.

    As for the location, one place to look for guidance would be the Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services, section K:

    Do not code conditions that were previously treated and no longer exist. However, history codes (v10-v19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

    There may be additional commentary, but I'd have to search for that--although I'm willing.

    Hope this provides the requested guidance! I know it's a sticky area...

  7. #17
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    To me, this implies a disease process such as cancer that has been treated or colon polyps - that have no recurrence (currently). There isn't a history code for abdominal pain that I'm aware of, so the history codes referenced lead me to believe my statement. I can't wrap my mind around not coding abdominal pain at a follow up appt even if it's resolved - why else is the patient there? I need more proof/guidance...
    Lisa Bledsoe, CPC, CPMA

  8. Default
    I agree with Lisa. The provider needs to follow up with the patient in regards to the status of the abdominal pain. Even though it's resolved, it's still being addressed.

    ~L
    CPC, CGSC, COSC

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