Ob-Gyn Coding Alert

Question: A patient presents with painful urination and a lab test confirms a UTI. Medication is prescribed and the patient is told to come back in a couple of weeks for a follow-up visit. The initial visit was linked to the diagnosis code for Urethritis (597.80). I would like to know if you still use the same diagnosis code when the patient returns for the follow up visit but now presents symptom and disease free?

Rosa Williams, Office Manager for Pepito B. Andres, MD

Answer: Yes. You know youre providing a successful service when a patient is treated and then returns apparently cured of the disease. This is what you hope for, but as long as the return visit is specifically to follow-up on the original diagnosis you use the same diagnosis code. Even though you know at the end of the visit that the patient no longer has the disease, the follow-up visit is to make sure.

Tip: Often a diagnosis code for the same problem in two separate visits will change. For example, a patient comes in with symptoms and that visit is linked to a diagnosis code for the symptoms. But between the first and second visit diagnostic tests confirm a diagnosis, so in the follow up visit the diagnosis code changes. Remember, the diagnosis code should always reflect what is definitely known.