# What is the best ICD 9 to bill for establishing care



## pamelat (Feb 20, 2015)

I work with family physicians and commonly patients will be seen to establish care, but not necessarily here for a preventive care visit.  What is the appropriate ICD 9 code to use when a patient is seen to establish care with a physician?


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## kimsggl (Feb 20, 2015)

There is no code for "establish care'.  To correctly code, I would need to see the note.  When a new patient is coming to establish care.  You can bill any issues that the physician addressed.  Does the patient have HTN? or any other common aliments?   If so you can code those.  But without the note it is hard to say.


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## teresabug (Feb 20, 2015)

if there is no medical condition for the dr to treat, then there is no reason for the patient to be seen.


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## lgardner (Feb 20, 2015)

we have used v65.40 (counseling, Nos).
the provider is spending time with the patient counseling him/her on how we provide care for our patients, what the patient can expect from our practice and, also, what we expect from our patients.


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## mitchellde (Feb 20, 2015)

V68.89 is the code for establishing care. Here is a listing of what this code is used for.
Disease Synonyms
Active advance directive
Administrative encounter for chart being opened in error
Administrative procedure for chart being opened in error done
Advance directive discussed with patient
Advance directive on file
Advanced directive discussed W patient
Advanced directive discussed with patient
Encounter for radiograph interpretation
Establish care or get acquainted visit
Establish care or get acquainted visit done
For resuscitation
Full code status
Immunizations are up to date
Immunizations up to date
Inconclusive retinal photography
Medication change
Medication change medication management done
Medication management
Patient deceased during stay
Radiograph interpretation done
Retinal photography, inconclusive
Review of medication done
Review of medications
Review of test results
Review of test results done
Up-to-date with immunizations
Vaccination records unavailable


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## pamelat (Feb 23, 2015)

Thanks everyone,

Mitchellde,
Can you please tell me where you found this information on the use of V68.89.  Also can you tell me if V68.89 is billable and if it can be used as a primary diagnosis?


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## pamelat (Feb 23, 2015)

More information on patient is:

Here to establish care,
Has history of Hypertension,
Concerns about low testosterone levels, but wanted to be referred to military facility for labs, treatment, etc.


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## mitchellde (Feb 23, 2015)

V68codes are first listed only, the information is in my code book


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## teresabug (Feb 23, 2015)

my concern is that the patients' insurance may not pay with this diagnosis. Codes for preventives such as V70.0, V20.X and V76.31 for women gyn preventives are typically the main payable codes. 
If the physician treated the patients' HTN at that visit then you can use 401.X as the dx. Not sure why this patient came in to establish care if he simply told the physician that he was going to go to a VA facility for treatment.


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## GaPeach77 (Feb 23, 2015)

Agree Teresa, I always suggest chronic conditions for primary diagnosis codes that require management.  Too many payers confused V codes with the limited amount of preventive care visits per patient. If a person  has HTN or 250.00 or other chronic condition that is a more specified code then the Vcode, IMO.


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## Thath041 (May 28, 2015)

Yes V68.89 is first listed only In the guidelines of the ICD-9 book .Where is the breakdown information that you listed out in the book? IT appears that information is from ICD9data.com which is not always perfectly accurate.


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