Question: If a patient receives treatment and the condition was resolved, which ICD-9 code should I report if the patient returns in six months for a follow-up visit?
Answer: The most accurate way to code visits to follow up on treatment for a previous condition is to report a V code as the primary diagnosis, with the condition that the optometrist is following up on as the secondary diagnosis.
You can find the follow-up V codes in the V67.x series in the ICD-9 manual. Although none specifically mention eye treatments, these are some examples of V codes that might be applicable:
- V67.00 — Follow-up examination; following surgery, unspecified
- V67.59 — … following other treatment; other
- V67.6 — … following combined treatment
- V67.9 — … unspecified follow-up examination.
However, some payers won’t accept a V code as a primary diagnosis to support payment. Some experts advise reporting the original diagnosis as the primary ICD-9 code, arguing that it best describes the reason the patient is being examined — if there were no original diagnosis, there would be no follow-up. Until the doctor pronounces the patient cured or has performed a procedure which effectively eliminates the original problem, the condition may still be the reason for follow-up. Use the V code as a secondary diagnosis, because it provides additional information for the office visit.
It is best to check with your payers for their policies on sequencing ICD-9 codes and the ICD-9-CM Official Guidelines for Coding and Reporting from the Center for Disease Control for follow-up visits. Your payer may interpret a follow-up visit as routine or part of global care and thus not reimbursable.
