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coding for resolved DX at f/up

  1. Default coding for resolved DX at f/up
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    Can anyone tell me if a patient comes back for a f/up appointment after receiving treatment and the condition is resovled at the f/up appointment, do you still code for the condition?

  2. #2
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    Quote Originally Posted by Lisa K Williams View Post
    Can anyone tell me if a patient comes back for a f/up appointment after receiving treatment and the condition is resovled at the f/up appointment, do you still code for the condition?
    It will depend.. if it is for an infection and the infection is deemed resolved at this encounter then you use the infection code. For any other condition you use a V67.x code for follow up

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default Follow up
    Thank you for that reply. Do you have a resource that I can quote (not to say that your word isn't enough )

    I'm also struggling with a provider who likes to use "follow up" as the cc for the visit, but without specifying what condition(s) the patient is being followed for. Is it appropriate to use the documented diagnosis then as the cc?

    Thanks.

  4. #4
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    hard to say I would need to read the entire progress note for the encounter.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    Here is the entire note.

    Reason for Visit
    Follow-Up 1 month follow-up

    Diagnoses
    CHF (congestive heart failure) [428.0S] - Primary
    Hypothyroid [244.9AA]



    Progress Notes
    Doing well, has been successfully cardioverted and holding NSR currently. Breathing and exercise capacity is improving. Now catheterizing himself twice per day. Discussed whether he can travel. Weight stable. Perfusion study was negative. Found to be hypothyroid on replacement
    Exam: vitals stable, blood pressure stable, chest clear,NSR, 1+ edema,no acites resolved.
    Imp: CHF, improved, hypothyroidism
    Rec: BMP, continue present meds, T4, watch for signs of UTI

  6. #6
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    It looks like a follow up following a cardioversion so I would go to the V67 category and select for followup following other procedure.

    Debra A. Mitchell, MSPH, CPC-H

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