Question: A personal pay patient visited for any well check. The internist then purchased a urinalysis, which returned abnormal. The individual returned within the next day to accept test again, which returned normal. For that second test’s diagnosis, the use of V67.59 (Following other treatment other) or V72.6 (Laboratory examination)?
Answer: Basically, you’re must use neither V67.59 nor V72.6 as the ICD-9 coding options. As a substitute, report day 1’s abnormality — for instance, hematuria (599.7x) or proteinuria (791.) — along with V67.9 (Unspecified follow-up examination). ).
The abnormality-V67.9 combo identifies this finding was discovered that motivated a recheck, where the condition was no more present. Some experts recommend while using V code alone as the ICD-9 coding option, which despite the fact that optimal coding, doesn’t meet insurers’ needs for confirming the initial problem.
ICD-9 identifies which you can use V67.9 as whether primary or secondary code. Payers generally prefer that you simply first list the main diagnosis — for instance, hematuria (382.9) — and secondarily list the recheck (V67.9).
For accurate , you would employ V67.9, instead of V67.59, because the patient didn’t get any strategy to the abnormality.
Just in case the internist had recommended antibiotic treatment, you’d as a substitute use V67.59. Prior antibiotic treatment counts as “other” in ICD-9’s V67.59 descriptor. Since grounds was gift for the recheck, V72.6 isn’t appropriate.
“V72.6 isn’t for use if any sign or signs and symptoms, or reason behind an evaluation is recorded,” according to ICD-9-Centimetres Official Recommendations Section I.C.18.d.15.
Tip: So far as are worried, you have to report the dipstick or specimen handling. Just in case staff completed the dipstick inside your office or shared lab, you have to assign 81000 (Urinalysis, by dip stick or tablet reagent – non-automated, with microscopy) or 81002 (- non-automated, without microscopy). As a substitute, report 99000 (Handling and/or conveyance of specimen for transfer in the physician’s office to some laboratory) if the outdoors lab completed the urinalysis. Code 99000 can also be targeted to mirror the job active in the preparation of the specimen before delivering it towards the [outdoors] laboratory.
Except the nurse did important evaluation and/or counseling, don’t report 99211 (Office or any other outpatient visit – Typically, a few minutes are spent carrying out or supervisory these types of services). A urine recheck alone doesn’t frequently support charging a medically necessary face-to- face encounter.