Primary Care Coding Alert

Question: One of our practitioners discussed sexual activity and contraception with an adolescent. Which ICD-9 codes are appropriate for this encounter?

Michigan Subscriber

Answer: The answer depends on the specifics of your discussion, but in general, the V25.0x codes (Encounter for contraceptive management; general counseling and advice) deal with counseling about various forms of contraception. For instance, you'll report V25.01 (Prescription of oral contraceptives) if the physician prescribes a birth control pill.

In addition, codes such as V65.44 (Human immunodeficiency virus [HIV] counseling) and V65.45 (Counseling on other sexually transmitted diseases) may be appropriate, depending on the discussion provided and documented by the physician.