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Conditions stated as "resolved" during visit

  1. Default Conditions stated as "resolved" during visit
    Medical Coding Books
    For an outpatient encounter, when a patient presents for evaulation of a condition that he/she had on the last visit, but now on the current visit that day, the MD (or a report dictated by a pathologist or radiologist) states that the condition has now resolved, what is the best way to code? Do I code what they had when they walked through the door (code current condition) or what was determined by the end of the visit (I assume I'll be using follow-up and history codes in that case. I would think this would be a very common situation and can find nothing clearly written about this concept. I know outpatient guidelines state "reason for encounter" but also state "do not code conditions resolved" as current.

  2. #2
    Default resolved
    I have always been told to code the reason for the visit. Even if they state resolved during the visit. I asked that very question and was told that as long as they present with that, that's what you code. You woulnd't code future visits with that as a current condition.
    i.e. Patient presents with OM right ear. treatment rendered and follow up in one week. When patient presents in one week OM resolved.
    Initial and one week visits will both be billed with OM as presenting diagnosis.

    anyone else?

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