Wiki Question about follow up visits in a family practice

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Carroll1220

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Hello!

I am stumped on how to code general follow up vists and would appreciate any assistance please.

We have a patient who has been seen multiple times for a cough and rales in the past few weeks. Because it is not resolved, would I just continue to use 786.2 for cough? Would I want to use an aftercare code or something like V67.9 (which I thought I couldn't use if the PT still had the the cough and was still being treated for it)?

Also, is there a code to use for a doctor reviewing the notes of a test done at a hospital or lab work? Or is that just included in the E&M?

Thank you for your assistance!
Noelle
 
You code the reason the patient is being seen, so if (s)he's still coming in for the cough and nothing else has been diagnosed you code 786.2. Reviewing of test results is included in the E/M.
 
Thank you so much, Doreen, for your response! It is much appreciated! I will do just that. It wouldn't need a modifier, either, if she was seen once on Friday and then once on the following Monday because there is no global period just for an office visit without any surgeries, is that correct?

Thank you again!
Noelle
 
No modifier needed

That is correct - no modifier would be added - you would just assign the proper E/M code for both the Friday and Monday visits.
 
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