Primary Care Coding Alert

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.