Internal Medicine Coding Alert

Question: A female patient who has had multiple previous urinary tract infections (UTIs) presents with a complaint of burning when urinating. Although the urinalysis comes back negative, the internist prescribes antibiotic treatment because of the patient's personal history of UTIs. Should I use V13.09 as the diagnosis code?


Florida Subscriber

Answer: Although your choice of V13.09 (Personal history of other diseases; disorders of urinary system; other) would have been correct prior to Oct. 1, on claims after this date you should instead use V13.02 (Personal history, urinary [tract] infection). This fall, ICD-9 introduced a specific fifth-digit subclassification to indicate that a patient requires treatment due to past UTIs. Prior to V13.02's creation, you had to lump personal history of UTI under "other specified personal history" V code V13.09

News flash: ICD-9 2006 also created a code for personal history of pneumonia (V12.61, Personal history, pneumonia [recurrent]). Use this diagnosis when an internist prescribes treatment for a patient who has a personal history of pneumonia but the physician doesn't note any signs and symptoms or a definitive diagnosis--or the test comes back negative.

Link V13.02 or V12.61 to the appropriate E/M service code (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

Answers for You Be the Coder and Reader Questions provided by Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.; Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on
compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise; and Maria M. Torres, CPC, CMM, with Bermudez Medical Consulting in Tampa, Fla.