Ocala Comprehensive Care, Ocala, Fla.
Answer: As always, the diagnosis code that should be used is the code that prompted either an office visit and/or service to be rendered. In this particular case, if the primary reason for the injection of the Depo-Provera to prevent menses and pregnancy is the patients congenital abnormality of Downs syndrome, the diagnosis code that should be used for billing purposes is 758.0 (Downs syndrome).
Ob/gyns should remember that one should always use the diagnosis code that is most specific to the reason why a procedure/service is rendered. If there had been additional problems or considerations that were related to the providers decision to give the patient Depo-Provera, those codes also should be listed.
For example, if the patient has signs/symptoms that would make her unable to care for a child, it would be appropriate to code those signs/symptoms. Another possibility for a secondary diagnosis code could be V25.8 (other specified contraceptive management), and this would qualify as the actual reason for using this medication for this particular patient.