Pediatric Coding Alert

Question: We see a patient each week to monitor her medication for depression. What is the best diagnosis code for these visits since we don't want to use a depression diagnosis?

Oklahoma Subscriber

Answer: The appropriate diagnosis depends on the type of physician seeing the patient. If the physician is a psychologist, report V67.3 (Follow-up examination; following psychotherapy and other treatment for mental disorder). For other physicians, submit V58.69 (Long-term [current] use of other medications).

The corresponding CPT code for managing the patient as described is 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy).

Note: If your provider sees a patient on a regular basis for medication follow-up, you'll reach a point where it's no longer appropriate to only code the patient's symptoms (unusual weight loss or gain, headache, fatigue, or other associated mental health issues). Once the patient has an official diagnosis of depression or another mental condition, you'll need to be straightforward in reporting that diagnosis.