Wiki Follow-Up/Aftercare Exams for Facility

[cter82]

When coding follow-up exams for the facility side, there is some debate in my office. The follow-up V code is put as primary diagnosis correct? If the patient has any new problems during this visit do we still code the follow-up code or does that go away and only the new problems get coded as the diagnosis?

Aftercare codes should always be primary with the reason of the aftercare as secondary correct (i.e. V58.44 Aftercare following organ transplant followed by V42.6 lung replace by transplant).

Thanks!

 

[GaPeach77]

Most of the time the follow-up post-op dx code would be coded first in align with the post-op global of 99024. But it would depend on the new problems. Are they problems unrelated to the procedure that was performed? If so one would not use the post-op dx or cpt code to begin with if the new problems were unrelated to the procedure. IF so, then you would use the post-op V codes and then the dx code identifying the complication or issue.

 

[mitchellde]

When coding follow-up exams for the facility side, there is some debate in my office. The follow-up V code is put as primary diagnosis correct? If the patient has any new problems during this visit do we still code the follow-up code or does that go away and only the new problems get coded as the diagnosis?

Aftercare codes should always be primary with the reason of the aftercare as secondary correct (i.e. V58.44 Aftercare following organ transplant followed by V42.6 lung replace by transplant).

Thanks!

Yes you are correct. as long as the primary reason for the encounter is for the follow-up. If the new problem is "discovered" during the encounter then it is considered an incidental issue and is coded secondary to the reason for the encounter which is follow-up. However if the patient presents for follow-up but has a serious over riding problem then it does negate the follow-up and the problem then becomes the reason for he encounter
As a sidebar.. Facilities do not bill the 99024 as the global concept does not apply to facility billing. The facility will bill the appropriate visit level per their individual facility E&M guidelines.