A patient that recently had a hysterectomy presented to the ED with symptoms needing treatment. The physician noted that the patient was suffering from “estrogen withdrawal with menopausal symptoms.” A level three evaluation and management service was performed on the patient; what diagnosis code would you use? There’s no specific code for estrogen withdrawal.

Stumped? In this case you should use more than one code as there is no specific code for this service. Break out the claim to show the patient’s main complaint and reason for the ED visit and then to show that she is a recent hysterectomy patient.

You will want to report code 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M service. Then you will want to pair that coding with 627.4 (Symptomatic states associated with artificial menopause) to 99283 to represent the patient’s estrogen withdrawal. Then, to back up the history of patient by attaching V45.77 (Acquired absence of organ; genital organs) to 99283 to signify that the patient had a hysterectomy.

Good documentation will show that this patient had a legitimate need for treatment and management and you are more likely to receive reimbursement for your medical billing claim if you meet this criteria.