How should I code a followup visit when the patient still has symptoms from the initial visit, has improved and is not receiving further treatment. For example a contusion that is not fully healed. The dx is stated 'followup for contusion to ***'.
Is this appropriate... V67.59, contusion code and E/M code?
Another example is the 3mo/6mo screening for blood borne pathogens due to needle stick. Is the followup code first and then screening code listed as a 'V' code or vice versa?
I am a new coder and would appreciate any tips you can offer. Thanks
There are four primary circumstances for the use of V codes:
1) A person who is not currently sick encounters the health services for some specific reason, such as to act as an organ donor, to receive prophylactic care, such as inoculations or health screenings, or to receive counseling on health related issues.
2) A person with a resolving disease or injury, or a chronic, long-term condition requiring continuous care, encounters the health care system for specific aftercare of that disease or injury (e.g., dialysis for renal disease; chemotherapy for malignancy; cast change). A diagnosis/symptom code should be used whenever a current, acute, diagnosis is being treated or a sign or symptom is being studied.
3) Circumstances or problems influence a person’s health status but are not in themselves a current illness or injury.
4) Newborns, to indicate birth status
The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes that explain current treatment for a healing condition or its sequelae. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code.
A follow-up code may be used to explain repeated visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code should be used in place of the follow-up code.
Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. Screenings that are recommended for many subgroups in a population include: routine mammograms for women over 40, a fecal occult blood test for everyone over 50, an amniocentesis to rule out a fetal anomaly for pregnant women over 35, because the incidence of breast cancer and colon cancer in these subgroups is higher than in the general population, as is the incidence of Down’s syndrome in older mothers.
The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.
A screening code may be a first listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination.
Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.
The V code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.
The Official ICD9 Guidelines can be found here: http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf
Thank you for your time in responding to my query and I apologize for not reading it sooner. I am still a bit confused with V67.59 in particular and how it can be used. The one example I used about the contusion required no treatment but was monitored and I couldn't find any other code to use. Would this code be appropriate? I had read the guidelines in detail but was at a loss. Someone else suggested V67.9 but I disagree because this record was a followup for someone previously seen for an injury. What do you think?
Also, the question regarding the blood borne pathogen was exposed to blood as a healthcare worker but showing no symptoms. I believe you indicated this would be a screening code due to the planned followup for testing. Is that correct?
I really appreciate you feedback. I do my best to review the guidelines but sometimes I'm still not clear and could use a second opinion. Thanks you very much!
Since the contusion has not fully healed I would use the contusion code. (f/u codes suggest that the condition has fully healed or no longer exists)
Since the visit is for a screening and they are performing some sort of screening test then I would report the V code for screening. Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.