Health Information Management

Ask the expert: A patient presents to a cardiologist, who makes a final diagnosis of "history of fen-phen exposure" and "mild mitral regurgitation, not hemodynamically significant." Which codes should I assign in this scenario?

HIM Connection, February 12, 2008

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A: Because this patient has a history of fen-phen exposure, the best code to report is V15.89. Fen-phen is a weight loss drug that was taken off the market. Refer to http://en.wikipedia.org/wiki/Fen-phen for more information. Do not report a code for the mild mitral regurgitation because the physician did not perform any treatment.  

Editor's note: Sandy Sillman, RHIT, PAHM, DRG coordinator for Henry Ford Health System in Detroit, answered this question.This Q&A appeared in the January 2008 issue of Briefings on Coding Compliance Strategies. For more information, visit http://www.hcpro.com/content/202988.cfm.



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