# Dx Resolved - this basic question but we have a physician



## P. Forster (Jul 29, 2008)

Please excuse this basic question but we have a physician that has started to add "resolved" to his Dx.  For example "abdominal pain - resolved".  Can we code this or is this like saying "probable"?

Thanks for your help!

These are initial ER visits for these HPI.  The symptoms have resolved prior to arriving at ER.  Sorry for not including this info earlier.

Thanks!


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## coder in mo (Jul 29, 2008)

I believe we can't code it if it's resolved, but I"m only about 70% sure of this.


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## meenal (Jul 29, 2008)

well he is actually using the word resolved instead of 'history of'. So I do not see a problem coding for it since it is one of the symptoms of the current case?


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## Lisa Bledsoe (Jul 29, 2008)

I agree...it is a symptom that the doctor was treating even though it has now resolved, so I think it's appropriate to code it.


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## Cottrell (Jul 29, 2008)

*resolved dx's*

According to CPT- "Do not code any condtions that were previously treated and no longer exist. However, History codes (V10-V19) may be used as secondary codes if the historical condition or family history has in impact on current care or influences treatment"

If your doc is doing what ours do-
pt here for follow-up abdominal pain
dx- abdominal pain resolved
look at the V67.59- Follow-up exam following other treatment

We use this one when we have that situation and they aren't treating anything else.


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## dmaec (Jul 29, 2008)

We always use the reason they're coming it (abdominal pain)... thankfully, it's resolved.  we do the same for sore throats when they come in for a follow up on that too.

Cottrell - I believe what you quoted is for example: if someone comes in with a sore throat today - two weeks ago they were in with abdominal pain - now resolved - today is being treated for the sore throat (only) - no reason to code the abdominal pain this time - "new" HPI = sore throat...


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## Lisa Bledsoe (Jul 30, 2008)

According to ICD-9-CM guidelines:  "Signs and symptoms - Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider."  

Abdominal pain is a symptom, so the way I _interpret_ this is that it can still be coded for the follow up visit even if it is resolved.


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## kevbshields (Jul 30, 2008)

Actually, the specific purpose of the follow up would need to be clearly stated in that record.

Coding symptoms and conditions that have resolved (outside using "history of") is inappropriate and misrepresentative--per the official, government-accepted ICD guidelines.

Sometimes as coders it's our duty to improve practices that are out of date or questionably compliant.  That may involve re-educating our providers or creating a documentation improvement program.  It may also involve more creative, but nonetheless compliant ways of dealing with documentation issues.

In the meantime, I wish everyone luck and encourage them to consider how the payer will review the record and claim against one another.  That should help to set policy.


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## FTessaBartels (Jul 30, 2008)

*This is for an ER visit*

So I see that P Forster edited the original question to clarify that this is for an initial ER visit, but that pain resolved before patient arrived.

Is there some other reason patient is in the ER?

If so, you may not have to code the resolved abdominal pain at all. 
Just because the claim allows for 4 dx codes does not mean you have to have 4 dx codes. 

F Tessa Bartels, CPC


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## P. Forster (Jul 30, 2008)

There is no other reason for the visit.  Thanks for helping!


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## Lisa Bledsoe (Jul 30, 2008)

kevbshields said:


> Actually, the specific purpose of the follow up would need to be clearly stated in that record.
> 
> Coding symptoms and conditions that have resolved (outside using "history of") is inappropriate and misrepresentative--per the official, government-accepted ICD guidelines.
> 
> ...




Can you point me in that direction then Kevin?  Because I am apparently doing it wrong.  My question then is, how many payers will pay for a V code with a problem oriented E/M?


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## scorrado (Jul 30, 2008)

I always thought that if the patient was seen for abdominal pain, doctor recommends treatment, and then wants to see patient back in two weeks that abdominal pain for the two week followup would be appropriate to code because that is the whole reason for the followup. The doctor wanted to see them back to see if the treatment worked. It is great that it has resolved but it is the reason the patient is there. 

I guess this is just one of those "grey" areas that we all have to deal with on a daily basis.


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## Treetoad (Jul 31, 2008)

I guess I was under the same impression as Susie.  I thought I was able to use abdominal pain for the follow up visit.  Even though the pain has resolved, it was still being addressed at this visit.  I'll need to re-think this one.


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## heatherwinters (Sep 4, 2008)

*Resolved Conditions*

If a patient is being seen for a follow up for thrush, and the patient's thrush has resolved, no other condition being treated that day, would you use V67.59?


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## Lliza71 (Sep 5, 2008)

*INITIAL ER visit*

Remember what F Tessa just posted....P Forster says these are *INITIAL *Er visits.  There is no follow up here. 

P Forster, I think we need to know why the pt had an ER visit. Did the pt come to the ER w/abdominal pain, but by the time the Dr came in to see the pt, it had resolved??  Or did the pt come to the ER for what he may have considered a "precautionary" visit because he had abd pain earlier?? It seems unneccesary to go to the ER when your pain is gone, unless maybe pt's a female who may be afraid of ectopic, etc...? 
How did you end up coding it, anyway?


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## kevbshields (Sep 5, 2008)

Apologies, I wasn't aware this thread was getting attention.

As for the location, one place to look for guidance would be the Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services, section K:

Do not code conditions that were previously treated and no longer exist.  However, history codes (v10-v19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

There may be additional commentary, but I'd have to search for that--although I'm willing.

Hope this provides the requested guidance!  I know it's a sticky area...


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## Lisa Bledsoe (Sep 5, 2008)

To me, this implies a disease process such as cancer that has been treated or colon polyps - that have no recurrence (currently).  There isn't a history code for abdominal pain that I'm aware of, so the history codes referenced lead me to believe my statement.  I can't wrap my mind around not coding abdominal pain at a follow up appt even if it's resolved - why else is the patient there?  I need more proof/guidance...


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## Treetoad (Sep 5, 2008)

I agree with Lisa.  The provider needs to follow up with the patient in regards to the status of the abdominal pain.  Even though it's resolved, it's still being addressed.


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