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Follow Up Encounter Coding

Tina Posted Mon 12th of January, 2015 11:51:15 AM

When rechecking a child about whom one is concerned, say the next day. I code the same diagnosis, as well as follow up encounter (V67.9). Is that correct? However if I bring back a child who had repeated ear infections and I want to check that he has finally cleared up after all treatment, should I still use the same diagnosis (otitis) and describe improvement /resolution in the notes?. In this situation does one also use the "follow up encounter" or not? Does using the follow up encounter typically result in less reimbursement? If so, that would make a simple problem focused visit like a 99212, almost free?

SuperCoder Answered Mon 12th of January, 2015 17:25:57 PM

Thank you for your question.

You are correct for a follow up encounter you would use diagnosis code V67.9, however you would not want to code otitis if the patient no longer has the issue. You can document the patient has improved but you don't want to essentially diagnosis the patient with something they don't have.

In most cases such as your example diagnosis will not impact reimbursement. Reimbursement is based on CPT code. If you were to code this scenario as a follow up and use 99212 you would be reimbursed your contracted rate by the payer for 99212.

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