Eli's Rehab Report

Question: We have had a few patients come to our practice suspecting that they had an illness, but it turned out they were healthy. Is there an ICD-9 code for this?

Virginia Subscriber

Answer: You should code the patient's symptoms, if there are any, along with a code from the V71 series, "Observation and evaluation for suspected conditions not found." For instance, suppose a patient presents for a facial twitch and asks you to determine whether she has Bell's palsy (351.0). You perform an examination but find no evidence that would necessitate further testing. Code the symptom (781.0, Abnormal involuntary movements) along with V71.89 (Observation for other specified suspected conditions).

If the patient presents with no symptoms, you should use V65.5 (Person with feared complaint in whom no diagnosis was made). For instance, suppose the physiatrist sees a patient in a nursing facility who has no symptoms but fears that she caught influenza from another patient. The physiatrist examines the patient and finds no illness whatsoever. This should be coded with V65.5, but many insurers will deny services provided with this code, so you should be as careful as possible to include any real symptoms or diagnoses first.

You Be the Coder and Reader Questions were reviewed by Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, consultant and CPC trainer for A+ Medical Management and Education in Absecon, N.J.