Wiki Help with coding a back exam

[amartinez1]

Patient received a letter from nurse at school stating that a screening was performed at school and spine showed curvature and high shoulders and will need to see physician to be tested and examined for scoliosis.

Patient came into the office and upon examination patient's spine showed to be perfectly aligned and his shoulders showed some abnormality with high AC bone. Xrays also showed good alignment of his spine. On examination the physician states lumbosacral spine and thoracic spine shows that he has normal flexion and extension without any bony deformity. He has normal lateral rotation and tilting of his spine. He has no CVA tenderness bilaterally. Examination of his right shoulder shows that he can flex and abduct to 180? and he has mild bony deformity at the right AC joint without any discomfort.

How would I code this since patient does not have scoliosis I really wouldn't want to use this as the diagnosis code. The doctor wants me to use diagnosis code for shoulder deformity and spine deformity. I don't think that is the correct diagnosis to use since it states in the note the spine looked normal with no abnormality. Also will the office visit be coded as a new patient intermediate (99203). Any suggestions will be greatly appreciated.

 

[mitchellde]

i would use a V71 code for condition not found.

 

[jesse.chavez@dielp.com]

well if you use v71. you will need a 4th or 5th digit. and under this code does not specify why the patient is being treated. i would take it as a v70.x. why you ask well the "nurse" suspected a "condition" which prompted her to have the child evaulated. so under HEALTH EXAMINATION OF DEFINED SUBPOPULATION> SCHOOL CHILDREN. v70.5with additional code v82.89 other specified conditions. hope this helps...

 

[mitchellde]

yes V71 needs additional characters i was stating to use a code from this category. It is appropriate for this scenario As the patient is coming in with a complaint of scoliosis, the screening has already been performed, therefore when a more indepth diagnostic shows no deformity present then it is a condition that the patient suspects but cannot be found on diagnostic study this is the purpose of the V71 codes.

 

[OCD_coder]

I must agree with Debra on this one. The V70.X codes won't get paid with an E&M code and a preventative E&M probably would not be appropriate when this was a exam performed at the request of a school nurse.

V71.89 code as Debra suggested, per ICD-9 instructions; This category is to be used when persons without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is found not to exist. This category is also for use for administrative and legal observation status.

Or maybe a worried well scenario V65.5 Feared condition not demonstrated, which in this case would be accurate. This diagnosis pays just fine with E&M codes 99201-99215 code families.