Question: A private pay patient visited for a well check. The internist then ordered a urinalysis, which came back abnormal. The patient came back in the next day to take the test again, which came back normal. For the second test's diagnosis, should you use V67.59 (Following other treatment; other) or V72.6 (Laboratory examination)?
Answer: Essentially, you are ought to use neither V67.59 nor V72.6 as your ICD-9 coding options. As an alternative, report day 1's abnormality -- for example, hematuria (599.7x) or proteinuria (791.0) -- together with V67.9 (Unspecified follow-up examination).
The abnormality-V67.9 combo specifies that this finding was found that prompted a recheck, in which the condition was no longer present. Some experts recommend using the V code alone as your ICD-9 coding option, which even though optimal coding, does not meet insurers' requirements for reporting the original problem.
ICD-9 specifies that you can use V67.9 as either a primary or secondary code. Payers generally prefer that you first list the primary diagnosis -- for example, hematuria (382.9) -- and secondarily list the recheck (V67.9).
For accurate ICD-9 coding , you would use V67.9, rather than V67.59, as the patient did not receive any treatment for the abnormality.
In case the internist had prescribed antibiotic treatment, you would as an alternative use V67.59. Prior antibiotic treatment counts as "other" in ICD-9's V67.59 descriptor. Since a reason was present for the recheck, V72.6 is not suitable.
"V72.6 is not to be used if any sign or symptoms, or reason for a test is documented," as per ICD-9-CM Official Guidelines Section I.C.18.d.15.
Medical Coding and Billing Tip: As far as CPT codes are concerned, you must report the dipstick or specimen handling. In case staff carried out the dipstick in your office or shared lab, you must assign 81000 (Urinalysis, by dip stick or tablet reagent … non-automated, with microscopy) or 81002 (… non-automated, without microscopy). As an alternative, report 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) if an outside lab carried out the urinalysis. Code 99000 is also aimed to reflect the work involved in the preparation of a specimen before sending it to the [outside] laboratory.
Except the nurse did important evaluation and/or counseling, do not report 99211 (Office or other outpatient visit … Typically, 5 minutes are spent performing or supervising these services). A urine recheck alone does not frequently support charging a medically necessary face-to- face encounter.