Internal Medicine Coding Alert
Withdrawal Symptoms = 'Artificial Menopause' Dx
Question: A new patient who had a hysterectomy earlier this year reported to the internist for treatment. The operative notes indicate that the patient was suffering from "estrogen withdrawal with menopausal symptoms." The physician performed a level two E/M service on the patient. Which diagnosis code (or codes) should I use on the claim? Answer: You should report a pair of ICD-9 codes for the encounter--one for the patient's chief complaint and another to show she is a hysterectomy patient. On the claim, report the following:
Nebraska Subscriber
• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making) for the E/M service
• 627.4 (Symptomatic states associated with artificial menopause) linked to 99202 to represent the patient's estrogen withdrawal
• V45.77 (Acquired absence of organ; genital organs) linked to 99202 to signify that the patient had a hysterectomy.
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