Advanced Search

Ob-Gyn Coding Alert

Track Urinary Infection, Osteoporosis History Over Patient's Lifetime

Published on Sat Jul 02, 2005

Tip: Use history code when condition reoccurs, not on first instance

Future care can be impacted by conditions of the past. Learn how to report the new personal and family history V codes to track specific conditions over the lifetime of a patient and potentially get procedures paid.

As of Oct. 1, you'll have the following new codes to report for a patient's personal and family history:
 

  • V13.02 - Personal history, urinary (tract) infection
     
  • V17.81 - Family history, osteoporosis.  

    Picture This: Perfect Personal History Coding

    According to CPT, past history includes the patient's experience with illnesses, injuries and treatments, including:  

  • prior major illnesses and injuries
     
  • prior operations
     
  • prior hospitalizations
     
  • current medications
     
  • allergies
     
  • age-appropriate immunization status
     
  • age-appropriate feeding/dietary status.

    So if a patient has a personal history of urinary tract infections, you'll be able to report V13.02 after Oct. 1.

    Heads up: If a patient has signs and symptoms of a disease or condition, you should list those first.

    "You should report a urinary tract infection (599.0) upon the first encounter as the primary diagnosis, then wait for it to reoccur to use the V code as an additional diagnosis," says Nadia Noor, CPC, a reimbursement specialist at the Austin Diagnostic Clinic in Texas.

    Also code the symptoms, such as urinary frequency, first and then follow up with V13.02, says a manager of ob-gyn services in Northern California.

    Flaunt Your Family History Coding Fundamentals

    According to CPT, family history includes a review of health-related events in the patient's family, including:  

  • health status or cause of death of parents, siblings and children
     
  • specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review
     
  • diseases of family members that may be hereditary or place the patient at risk.

    For patients with osteoporosis in their family, you'll be able to apply V17.81.  "I would use V codes whenever they impacted a patient's status," the manager says.

    A patient with a family history of osteoporosis may be more apt to receive reimbursement for a DEXA bone scan (76075, Dual energy x-ray absorptiometry [DEXA], bone density study, one or more sites; axial skeleton [e.g., hips, pelvis, spine]; or 76076, Dual energy x-ray absorptiometry [DEXA], bone density study, one or more sites; appendicular skeletal [peripheral] [e.g., radius, wrist, heel]).
     
    Such scans are not routine. The ob-gyn must document medical history supporting the medical necessity for the test - and this new V code can help.

    • Other Articles in this issue of

    Ob-Gyn Coding Alert

    View All