Internal Medicine Coding Alert

Question: A private pay patient came in for a well check. The internist ordered a urinalysis, which came back abnormal. The patient came back in the next day to repeat the test, which came back normal. For the second test's diagnosis, should I use V67.59 (Following other treatment; other) or V72.6 (Laboratory examination)?

Arkansas Subscriber

Answer: Actually, you should use neither V67.59 nor V72.6. Instead, report day 1's abnormality -- for instance, hematuria (599.7x) or proteinuria (791.0) -- along with V67.9 (Unspecified follow-up examination).

The abnormality-V67.9 combo indicates that this finding was found that prompted a recheck, in which the condition was no longer present. Some experts suggest using the V code alone, which although optimal coding, does not meet insurers' requirements for reporting the original problem.

ICD-9 2010 indicates you can use V67.9 as either a primary or secondary code. Payers usually prefer that you first list the primary diagnosis -- for instance, hematuria (382.9) -- and secondarily list the recheck (V67.9).

You would use V67.9, rather than V67.59, because the patient did not receive any treatment for the abnormality.

If the internist had prescribed antibiotic treatment, you would instead use V67.59. Prior antibiotic treatment counts as "other" in ICD-9's V67.59 descriptor. Since a reason existed for the recheck, V72.6 is not appropriate.

"V72.6 is not to be used if any sign or symptoms, or reason for a test is documented," according to ICD-9-CM Official Guidelines Section I.C.18.d.15.

Don't miss: For the CPT codes, report the dipstick or specimen handling. If staff performed the dipstick in your office or shared lab, assign 81000 (Urinalysis, by dip stick or tablet reagent ... non-automated, with microscopy) or 81002 (... non-automated, without microscopy). Instead, report 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) if an outside lab performed the urinalysis. "Code 99000 is also intended to reflect the work involved in the preparation of a specimen prior to sending it to the [outside] laboratory," states CPT Assistant October 1999.

Unless the nurse did significant evaluation and/or counseling, do not report 99211 (Office or other outpatient visit ... Typically, 5 minutes are spent performing or supervising these services). A urine recheck alone does not usually support charging a medically necessary faceto- face encounter.