Wiki HELP ! OV with no diagnosis

[madgejones10]

A young man wishes to get into a service academy (US AIRFORCE) but had prior knee problems, now resolved completely with no restrictions.

He comes in for exam to document strength, ROM, etc. There are no lingering problems. He has no pain or limitations.

There is no diagnosis (no complaints whatsoever).

What CPT code do we use and what ICD-9 code????

I AM BAFFLED !!!!! PLEASE HELP !!!

 

[PWright]

If there is no problems at all, then this would be a preventive visit (physical) with V70.0 or V70.5

 

[btadlock1]

A young man wishes to get into a service academy (US AIRFORCE) but had prior knee problems, now resolved completely with no restrictions.

He comes in for exam to document strength, ROM, etc. There are no lingering problems. He has no pain or limitations.

There is no diagnosis (no complaints whatsoever).

What CPT code do we use and what ICD-9 code????

I AM BAFFLED !!!!! PLEASE HELP !!!

You need to get clarification on whether the exam was done at the request of the military, specifically for the military, or if it was a precaution taken by the patient on their own, without the military's knowledge - it will impact billing.

If the military is involved, the CPT will probably be 99455 or 99456, with diagnosis codes: V70.5 (has to be primary), with possible secondary diagnosis of V13.59 or V15.59

If the military's not involved, use a regular preventive exam CPT, with V70.0 and any applicable secondary diagnosis (V13.59, or V15.59). Hope that helps!