Ob-Gyn Coding Alert

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.