Primary Care Coding Alert

Question: An established patient who had a hysterectomy six months ago came to the FP for treatment. The op notes indicate that the patient was suffering from -estrogen withdrawal with menopausal symptoms.- The FP performed a level-three evaluation and management service on the patient. Which diagnosis code(s) should I use on the claim?

Nebraska Subscriber

Answer: You should report a pair of ICD-9 codes for the encounter -- one for the patient's chief complaint, and another to show that she is a hysterectomy patient.

On the claim:

 - report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M service.

 - attach 627.4 (Symptomatic states associated with artificial menopause) to 99213 to represent the patient's estrogen withdrawal.

 - attach V45.77 (Acquired absence of organ; genital organs) to 99213 to signify that the patient had a hysterectomy.