Several new codes describe personal history. Code V11.4 is used to describe personal history of mental disorder associated with combat and operational stress reaction. Combat and operational stress reaction was added as an inclusion term to category 308, Acute reaction to stress.
Two new codes have been created to describe personal history of genital system and obstetric disorders: personal history of vaginal dysplasia (V13.23) and personal history of vulvar dysplasia (V13.24).
Code V13.6, Congenital malformations, has been expanded to further identify personal history of congenital malformations by body system or body area, such as genitourinary system (V13.62), nervous system (V13.63), eye, ear, face and neck (V13.64) , heart and circulatory system (V13.65), respiratory system (V13.66), digestive system (V13.67), integument, limbs, and musculoskeletal systems (V13.68), and other congenital malformations (V13.69). In addition, the term "corrected" has been added as a nonessential modifier to clarify that subcategory V13.6 may be used to report congenital malformations that may still be present, but not requiring additional care, as well as corrected malformations that are no longer present. Due to advances in medical science, many congenital conditions can be repaired and the patients are left with little or no residual condition.
Code V15.53, Personal history of retained foreign body fully removed, has been created to allow the tracking of patients who may have had a retained foreign body, which is no longer present having previously had the foreign body fully removed.
Subcategory V07.5, Prophylactic use of agents affecting estrogen receptors and estrogen levels, has been revised so that these codes are no longer used only for prophylactic use. They may be used for situations when these agents are used for treatment as well.
Two new status codes have been created as follows:
- V49.86 Do not resuscitate status. This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay.
- V49.87 Physical restraints status. This code may be used when it is documented by the provider that a patient has been put in restraints during the current encounter. Please note that this code should not be reported when it is documented by the provider that a patient is temporarily restrained during a procedure.
Code V85.4, Body mass index, 40 and over, adult, has been expanded to create five new codes to provide greater specificity to identify patients with a body mass index (BMI) over 40. The new codes are as follows:
- V85.41 Body Mass Index 40.0-44.9, adult
- V85.42 Body Mass Index 45.0-49.9, adult
- V85.43 Body Mass Index 50.0-59.9, adult
- V85.44 Body Mass Index 60.0-69.9, adult
- V85.45 Body Mass Index 70 and over, adult
A new category has been created to report retained foreign body status. These codes may be used to report the patient status of embedded fragments, embedded splinters, as well as retained foreign bodies, which have been retained over a period of time. Unique codes have been created for different types of retained materials such as radioactive fragments (V90.01 and V90.09), metal fragments (V90.10, V90.11, and V90.12), plastic fragments (V90.2), organic fragments (V90.31, V90.32, V90.33, V90.39), other specified retained foreign body (V90.81, V90.83 and V90.89), and unspecified material (V90.9). These codes should be used to report foreign bodies that have been retained over a period of time.
Counseling and Obstetrics and Related Conditions
Codes in category V25, Encounter for contraceptive management, have been revised to allow better classification of encounters for intrauterine contraceptive device (IUD) insertion and management. Prior to this change, encounters for the insertion of an IUD were coded to V25.1; while the routine checking, removal and any subsequent reinsertion of an IUD was coded to V25.42. The new codes are as follows:
- V25.11 Encounter for insertion of intrauterine contraceptive device,
- V25.12 Encounter for removal of intrauterine contraceptive device, and
- V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device
In addition, the inclusion note at code V25.42, Surveillance of previously prescribed contraceptive methods, Intrauterine contraceptive device, has been revised to clarify that this code should no longer be used for the reinsertion or removal of IUDs. Instead, the new codes V25.13 or V25.12 should be used for these encounters.
A new category (V91) has been created to report multiple gestation placenta status. These new codes specify the number of placentas and amniotic sacs. The risk of complications will increase, and the treatment plan will differ, depending on the number of placentas and amniotic sacs. Subcategory V91.0 is for twin gestation placenta status; subcategory V91.1 is for triplet gestation placenta status; subcategory V91.2 is for quadruplet gestation placenta status; while subcategory V91.9 is for other specified multiple gestation placenta status.
A new code has been created to identify patients with homicidal ideation (V62.85).