Primary Care Coding Alert

Reader Question:

Worried Well Works With Prevacation Check

Question: A mother presents to make sure her child's ears are clear prior to flying. Although the child has a history of otitis media, she doesn't now have an infection. How should I report the visit? Which diagnosis code should I use?

Michigan Subscriber

Answer: You should submit the appropriate-level office visit code (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) based on the history, examination and medical decision-making that the family physician documents.

To show that your FP didn't find a problem, report the worried well diagnosis V65.5 (Person with feared complaint in whom no diagnosis was made) in the secondary position.

-- Information for You Be the Coder and Reader Questions provided by Victoria Jackson, executive director and owner, Omni Management, El Torro, Calif.; Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians; and Richard H. Tuck, MD, FAAP, pediatrician at Primecare of Southeastern Ohio in Zanesville.

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