Pediatric Coding Alert

Question: A child comes in for a penile lesion, and he is surgically treated and comes back in three months for a follow-up. The lesion is healed at the three-month f/u. Should I use V67.9 for the follow-up and the penile lesion code or just the follow-up V code?


New York Subscriber


Answer: You are in the right V code series: V67.x (Follow-up examination). When a pediatrician examines a patient for a condition that is no longer present, you should use V67.xx. This series indicates that the child did not receive any treatment at this encounter and the condition (penile lesion) is resolved.

But within the V67.xx series, a better V code choice exists than the one you mention. Because in your case the exam is for surgical follow-up (54050, Destruction of lesion[s], penis [e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle], simple; chemical or 54056, ... cryosurgery) of a condition that no longer exists, you should instead use V67.09 (Follow-up exam; following other surgery) with the E/M service code (such as 99212, Office or other outpatient visit for the evaluation and management of an established patient ...).

If the original treatment did not include surgery (V67.09) or antibiotics (V67.59, Follow-up exam; following other treatment; other), you should instead assign V67.9 (Unspecified follow-up examination).

Whether you need the penile lesion code depends on the applicable guideline. According to ICD-9 guidelines, you should use only the follow-up V code. But insurers may require you to also report the penile lesion diagnosis, for instance, 078.19 (Other diseases due to viruses and Chlamydiae; other specified viral warts), in either the primary or secondary position and the V code in the other position. Best bet: Ask the payer for its policy.

Bottom line: Optimal coding for a penile lesion follow-up exam in which the condition is no longer found would be V67.09. But payers typically prefer that you use 078.19 as the primary diagnosis and V67.59 in the second position. Answers to You Be the Coder and Reader Questions reviewed/provided by Joel Bradley Jr., MD, FAAP, pediatrician at Premier Medical Group in Clarksville, Tenn.; Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG--Children's Healthcare of Atlanta at Egleston; Victoria S. Jackson, practice management consultant with JCM Inc. in California; and Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.