Ob-Gyn Coding Alert

Question: We have a patient with a positive BRCA2. Within the last year and a half, she has had a bilateral mastectomy. Due to the BRCA2, she has been referred to us for removal of her ovaries and uterus. She desires the surgery but doesn't want the BRCA2 labeling her. Essentially, this is a prophylactic removal of her ovaries and uterus due to the recent history of breast cancer. I am not sure which diagnosis to use when requesting prior authorization from her insurance carrier: 174.8 or V15.89?


Missouri Subscriber


Answer: Does your patient understand that because this is prophylactic surgery, her insurance carrier will likely not pay for it because you are hampered from reporting diagnosis codes that will support medical necessity? Trying to pretend that the reason for the surgery is not related to her history is not going to fool the payer. -Coding versus coverage- should be the watchword here, and you definitely don't want to be coding incorrectly. 

Under ICD-9 coding rules, you can report V50.42 (Prophylactic removal of ovary) and/or V50.8 (Prophylactic removal of other organ), but your second code needs to be the personal history of breast cancer, V10.3 (Personal history of malignant neoplasm; breast). You may also want to report V84.02 (Genetic susceptibility to malignant neoplasm of ovary). 

Watch out: The patient no longer has breast cancer, so you cannot use 174.8 (Malignant neoplasm of female breast; other specified sites of female breast). Code V15.89 (Other specified personal history presenting hazards to health; other) is also not appropriate because you have a more specific code that accurately reports this circumstance.