Virginia Subscriber Answer: Reporting V codes to provide a better picture to payers is a useful tool, especially because conditions of the past can impact future care.
Personal history: According to CPT, past personal history includes the patient's experience with illnesses, injuries and treatments, including:
- prior major illnesses and injuries
- prior operations
- prior hospitalizations
- current medications
- age-appropriate immunization status
- age-appropriate feeding/dietary status. Although CPT provides this definition, it carries over to the diagnosis code you can assign to the encounter. For example, if your ob-gyn sees a patient with a urinary tract infection, you should report 599.0 (Urinary tract infection, site not specified) upon the first encounter as the primary diagnosis.
When the infection reoccurs, you can report V13.02 (Personal history; urinary [tract] infection) as an additional diagnosis. Also code the symptoms, such as urinary frequency (788.41), first and then follow up with V13.02.
Family history: According to CPT, family history includes a review of health-related events in the patient's family, such as:
- 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 example, if the ob-gyn sees a patient with osteoporosis in her family, you-ll be able to apply V17.81 (Family history; osteoporosis).
If your ob-gyn sees a patient with a family history of osteoporosis, your practice 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, ... appendicular skeleton [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 V17.81 can help.