Classification of Factors Influencing Health Status and Contact with Health Service (Supplemental V01-V89)
Note: The chapter specific guidelines provide additional information about the use of V codes for specified encounters.
a. Introduction
ICD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01.0 - V89.09) is provided to deal with occasions when circumstances other than a disease or injury (codes 001-999) are recorded as a diagnosis or problem.
There are four primary circumstances for the use of V codes:
1) A person who is not currently sick encounters the health services for some specific reason, such as to act as an organ donor, to receive prophylactic care, such as inoculations or health screenings, or to receive counseling on health related issues.
2) A person with a resolving disease or injury, or a chronic, long-term condition requiring continuous care, encounters the health care system for specific aftercare of that disease or injury (e.g., dialysis for renal disease; chemotherapy for malignancy; cast change). A diagnosis/symptom code should be used whenever a current, acute, diagnosis is being treated or a sign or symptom is being studied.
3) Circumstances or problems influence a person’s health status but are not in themselves a current illness or injury.
4) Newborns, to indicate birth status
b. V codes use in any healthcare setting
V codes are for use in any healthcare setting. V codes may be used as either a first listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain V codes may only be used as first listed, others only as secondary codes.
See Section I.C.18.e, V Code Table.
c. V Codes indicate a reason for an encounter
They are not procedure codes. A corresponding procedure code must accompany a V code to describe the procedure performed.
d. Categories of V Codes
1) Contact/Exposure
Category V01 indicates contact with or exposure to communicable diseases. These codes are for patients who do not show any sign or symptom of a disease but have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic. These codes may be used as a first listed code to explain an encounter for testing, or, more commonly, as a secondary code to identify a potential risk.
2) Inoculations and vaccinations
Categories V03-V06 are for encounters for inoculations and vaccinations. They indicate that a patient is being seen to receive a prophylactic inoculation against a disease. The injection itself must be represented by the appropriate procedure code. A code from V03-V06 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit.
3) Status
Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. A status code is informative, because the status may affect the course of treatment and its outcome. A status code is distinct from a history code. The history code indicates that the patient no longer has the condition.
A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For example, code V42.1, Heart transplant status, should not be used with code 996.83, Complications of transplanted heart. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient.
The status V codes/categories are:
V02 Carrier or suspected carrier of infectious diseases
Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection.
V07.5X Prophylactic use of agents affecting estrogen receptors and estrogen level
This code indicates when a patient is receiving a drug that affects estrogen receptors and estrogen levels for prevention of cancer.
V08 Asymptomatic HIV infection status
This code indicates that a patient has tested positive for HIV but has manifested no signs or symptoms of the disease.
V09 Infection with drug-resistant microorganisms
This category indicates that a patient has an infection that is resistant to drug treatment. Sequence the infection code first.
V21 Constitutional states in development
V22.2 Pregnant state, incidental
This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required.
V26.5x Sterilization status
V42 Organ or tissue replaced by transplant
V43 Organ or tissue replaced by other means
V44 Artificial opening status
V45 Other postsurgical states
Assign code V45.87, Transplant organ removal status, to indicate that a transplanted organ has been previously removed. This code should not be assigned for the encounter in which the transplanted organ is removed. The complication necessitating removal of the transplant organ should be assigned for that encounter.
See section I.C17.f.2. for information on the coding of organ transplant complications.
Assign code V45.88, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to the current facility, as a secondary diagnosis when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activator (tPA) within the last 24 hours prior to admission to the current facility.
This guideline applies even if the patient is still receiving the tPA at the time they are received into the current facility.
The appropriate code for the condition for which the tPA was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first.
Code V45.88 is only applicable to the receiving facility record and not to the transferring facility record.
V46 Other dependence on machines
V49.6 Upper limb amputation status
V49.7 Lower limb amputation status
Note: Categories V42-V46, and subcategories V49.6, V49.7 are for use only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment on which the patient is dependent.
V49.81 Postmenopausal status
V49.82 Dental sealant status
V49.83 Awaiting organ transplant status
V58.6x Long-term (current) drug use
Codes from this subcategory indicate a patient’s continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead.
Assign a code from subcategory V58.6, Long-term (current) drug use, if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from subcategory V58.6 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis).
V83 Genetic carrier status
Genetic carrier status indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. The person does not have the disease and is not at risk of developing the disease.
V84 Genetic susceptibility status
Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease.
Codes from category V84, Genetic susceptibility to disease, should not be used as principal or first-listed codes. If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced first. If the patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow-up code should be sequenced first, followed by the appropriate personal history and genetic susceptibility codes. If the purpose of the encounter is genetic counseling associated with procreative management, a code from subcategory V26.3, Genetic counseling and testing, should be assigned as the first-listed code, followed by a code from category V84. Additional codes should be assigned for any applicable family or personal history.
See Section I.C. 18.d.14 for information on prophylactic organ removal due to a genetic susceptibility.
V86 Estrogen receptor status
V88 Acquired absence of other organs and tissue
4) History (of)
There are two types of history V codes, personal and family. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. The exceptions to this general rule are category V14, Personal history of allergy to medicinal agents, and subcategory V15.0, Allergy, other than to medicinal agents. A person who has had an allergic episode to a substance or food in the past should always be considered allergic to the substance.
Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.
Personal history codes may be used in conjunction with follow-up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.
The history V code categories are:
V10 Personal history of malignant neoplasm
V12 Personal history of certain other diseases
V13 Personal history of other diseases
Except: V13.4, Personal history of arthritis, and V13.6, Personal history of congenital malformations. These conditions are life-long so are not true history codes.
V14 Personal history of allergy to medicinal agents
V15 Other personal history presenting hazards to health
Except: V15.7, Personal history of contraception.
V16 Family history of malignant neoplasm
V17 Family history of certain chronic disabling diseases
V18 Family history of certain other specific diseases
V19 Family history of other conditions
V87 Other specified personal exposures and history presenting hazards to health
5) Screening
Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. Screenings that are recommended for many subgroups in a population include: routine mammograms for women over 40, a fecal occult blood test for everyone over 50, an amniocentesis to rule out a fetal anomaly for pregnant women over 35, because the incidence of breast cancer and colon cancer in these subgroups is higher than in the general population, as is the incidence of Down’s syndrome in older mothers.
The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.
A screening code may be a first listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems. A screening code is not necessary if the screening is inherent to a routine examination, such as a pap smear done during a routine pelvic examination.
Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.
The V code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.
The screening V code categories:
V28 Antenatal screening
V73-V82 Special screening examinations
6) Observation
There are three observation V code categories. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding E code to identify any external cause.
The observation codes are to be used as principal diagnosis only. The only exception to this is when the principal diagnosis is required to be a code from the V30, Live born infant, category. Then the V29 observation code is sequenced after the V30 code. Additional codes may be used in addition to the observation code but only if they are unrelated to the suspected condition being observed.
Codes from subcategory V89.0, Suspected maternal and fetal conditions not found, may either be used as a first listed or as an additional code assignment depending on the case. They are for use in very limited circumstances on a maternal record when an encounter is for a suspected maternal or fetal condition that is ruled out during that encounter (for example, a maternal or fetal condition may be suspected due to an abnormal test result). These codes should not be used when the condition is confirmed. In those cases, the confirmed condition should be coded. In addition, these codes are not for use if an illness or any signs or symptoms related to the suspected condition or problem are present. In such cases the diagnosis/symptom code is used.
Additional codes may be used in addition to the code from subcategory V89.0, but only if they are unrelated to the suspected condition being evaluated.
Codes from subcategory V89.0 may not be used for encounters for antenatal screening of mother. See Section I.C.18.d., Screening).
For encounters for suspected fetal condition that are inconclusive following testing and evaluation, assign the appropriate code from category 655, 656, 657 or 658.
The observation V code categories:
V29 Observation and evaluation of newborns for suspected condition not found
For the birth encounter, a code from category V30 should be sequenced before the V29 code.
V71 Observation and evaluation for suspected condition not found
V89 Suspected maternal and fetal conditions not found
7) Aftercare
Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare V code should not be used if treatment is directed at a current, acute disease or injury. The diagnosis code is to be used in these cases. Exceptions to this rule are codes V58.0, Radiotherapy, and codes from subcategory V58.1, Encounter for chemotherapy and immunotherapy for neoplastic conditions. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy or chemotherapy for the treatment of a neoplasm. Should a patient receive both chemotherapy and radiation therapy during the same encounter code V58.0 and V58.1 may be used together on a record with either one being sequenced first.
The aftercare codes are generally first listed to explain the specific reason for the encounter. An aftercare code may be used as an additional code when some type of aftercare is provided in addition to the reason for admission and no diagnosis code is applicable. An example of this would be the closure of a colostomy during an encounter for treatment of another condition.
Aftercare codes should be used in conjunction with any other aftercare codes or other diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification. The sequencing of multiple aftercare codes is discretionary.
Certain aftercare V code categories need a secondary diagnosis code to describe the resolving condition or sequelae, for others, the condition is inherent in the code title.
Additional V code aftercare category terms include fitting and adjustment, and attention to artificial openings.
Status V codes may be used with aftercare V codes to indicate the nature of the aftercare. For example code V45.81, Aortocoronary bypass status, may be used with code V58.73, Aftercare following surgery of the circulatory system, NEC, to indicate the surgery for which the aftercare is being performed. Also, a transplant status code may be used following code V58.44, Aftercare following organ transplant, to identify the organ transplanted. A status code should not be used when the aftercare code indicates the type of status, such as using V55.0, Attention to tracheostomy with V44.0, Tracheostomy status.
See Section I. B.16 Admissions/Encounter for Rehabilitation
The aftercare V category/codes:
V51.0 Encounter for breast reconstruction following mastectomy
V52 Fitting and adjustment of prosthetic device and implant
V53 Fitting and adjustment of other device
V54 Other orthopedic aftercare
V55 Attention to artificial openings
V56 Encounter for dialysis and dialysis catheter care
V57 Care involving the use of rehabilitation procedures
V58.0 Radiotherapy
V58.11 Encounter for antineoplastic chemotherapy
V58.12 Encounter for antineoplastic immunotherapy
V58.3x Attention to dressings and sutures
V58.41 Encounter for planned post-operative wound closure
V58.42 Aftercare, surgery, neoplasm
V58.43 Aftercare, surgery, trauma
V58.44 Aftercare involving organ transplant
V58.49 Other specified aftercare following surgery
V58.7x Aftercare following surgery
V58.81 Fitting and adjustment of vascular catheter
V58.82 Fitting and adjustment of non-vascular catheter
V58.83 Monitoring therapeutic drug
V58.89 Other specified aftercare
8) Follow-up
The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. They should not be confused with aftercare codes that explain current treatment for a healing condition or its sequelae. Follow-up codes may be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. The follow-up code is sequenced first, followed by the history code.
A follow-up code may be used to explain repeated visits. Should a condition be found to have recurred on the follow-up visit, then the diagnosis code should be used in place of the follow-up code.
The follow-up V code categories:
V24 Postpartum care and evaluation
V67 Follow-up examination
9) Donor
Category V59 is the donor codes. They are used for living individuals who are donating blood or other body tissue. These codes are only for individuals donating for others, not for self donations. They are not for use to identify cadaveric donations.
10) Counseling
Counseling V codes are used when a patient or family member receives assistance in the aftermath of an illness or injury, or when support is required in coping with family or social problems. They are not necessary for use in conjunction with a diagnosis code when the counseling component of care is considered integral to standard treatment.
The counseling V categories/codes:
V25.0 General counseling and advice for contraceptive management
V26.3 Genetic counseling
V26.4 General counseling and advice for procreative management
V61.X Other family circumstances
V65.1 Person consulted on behalf of another person
V65.3 Dietary surveillance and counseling
V65.4 Other counseling, not elsewhere classified
11) Obstetrics and related conditions
See Section I.C.11., the Obstetrics guidelines for further instruction on the use of these codes.
V codes for pregnancy are for use in those circumstances when none of the problems or complications included in the codes from the Obstetrics chapter exist (a routine prenatal visit or postpartum care). Codes V22.0, Supervision of normal first pregnancy, and V22.1, Supervision of other normal pregnancy, are always first listed and are not to be used with any other code from the OB chapter.
The outcome of delivery, category V27, should be included on all maternal delivery records. It is always a secondary code.
V codes for family planning (contraceptive) or procreative management and counseling should be included on an obstetric record either during the pregnancy or the postpartum stage, if applicable.
Obstetrics and related conditions V code categories:
V22 Normal pregnancy
V23 Supervision of high-risk pregnancy
Except: V23.2, Pregnancy with history of abortion. Code 646.3, Habitual aborter, from the OB chapter is required to indicate a history of abortion during a pregnancy.
V24 Postpartum care and evaluation
V25 Encounter for contraceptive management
Except V25.0x
(See Section I.C.18.d.11, Counseling)
V26 Procreative management
Except V26.5x, Sterilization status, V26.3 and V26.4
(See Section I.C.18.d.11., Counseling)
V27 Outcome of delivery
V28 Antenatal screening
(See Section I.C.18.d.6., Screening)
12) Newborn, infant and child
See Section I.C.15, the Newborn guidelines for further instruction on the use of these codes.
Newborn V code categories:
V20 Health supervision of infant or child
V29 Observation and evaluation of newborns for suspected condition not found
(See Section I.C.18.d.7, Observation)
V30-V39 Liveborn infant according to type of birth
13) Routine and administrative examinations
The V codes allow for the description of encounters for routine examinations, such as, a general check-up, or, examinations for administrative purposes, such as, a pre-employment physical. The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code. Pre-existing and chronic conditions and history codes may also be included as additional codes as long as the examination is for administrative purposes and not focused on any particular condition.
Pre-operative examination V codes are for use only in those situations when a patient is being cleared for surgery and no treatment is given.
The V codes categories/code for routine and administrative examinations:
V20.2 Routine infant or child health check
Any injections given should have a corresponding procedure code.
V70 General medical examination
V72 Special investigations and examinations
Codes V72.5 and V72.6 may be used if the reason for the patient encounter is for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test.
14) Miscellaneous V codes
The miscellaneous V codes capture a number of other health care encounters that do not fall into one of the other categories. Certain of these codes identify the reason for the encounter, others are for use as additional codes that provide useful information on circumstances that may affect a patient’s care and treatment.
Prophylactic Organ Removal
For encounters specifically for prophylactic removal of breasts, ovaries, or another organ due to a genetic susceptibility to cancer or a family history of cancer, the principal or first listed code should be a code from subcategory V50.4, Prophylactic organ removal, followed by the appropriate genetic susceptibility code and the appropriate family history code.
If the patient has a malignancy of one site and is having prophylactic removal at another site to prevent either a new primary malignancy or metastatic disease, a code for the malignancy should also be assigned in addition to a code from subcategory V50.4. A V50.4 code should not be assigned if the patient is having organ removal for treatment of a malignancy, such as the removal of the testes for the treatment of prostate cancer.
Miscellaneous V code categories/codes:
V07 Need for isolation and other prophylactic measures
Except V07.5, Prophylactic use of agents affecting estrogen receptors and estrogen levels
V50 Elective surgery for purposes other than remedying health states
V58.5 Orthodontics
V60 Housing, household, and economic circumstances
V62 Other psychosocial circumstances
V63 Unavailability of other medical facilities for care
V64 Persons encountering health services for specific procedures, not carried out
V66 Convalescence and Palliative Care
V68 Encounters for administrative purposes
V69 Problems related to lifestyle
V85 Body Mass Index
15) Nonspecific V codes
Certain V codes are so non-specific, or potentially redundant with other codes in the classification, that there can be little justification for their use in the inpatient setting. Their use in the outpatient setting should be limited to those instances when there is no further documentation to permit more precise coding. Otherwise, any sign or symptom or any other reason for visit that is captured in another code should be used.
Nonspecific V code categories/codes:
V11 Personal history of mental disorder
A code from the mental disorders chapter, with an in remission fifth-digit, should be used.
V13.4 Personal history of arthritis
V13.6 Personal history of congenital malformations
V15.7 Personal history of contraception
V23.2 Pregnancy with history of abortion
V40 Mental and behavioral problems
V41 Problems with special senses and other special functions
V47 Other problems with internal organs
V48 Problems with head, neck, and trunk
V49 Problems with limbs and other problems
Exceptions:
V49.6 Upper limb amputation status
V49.7 Lower limb amputation status
V49.81 Postmenopausal status
V49.82 Dental sealant status
V49.83 Awaiting organ transplant status
V51.8 Other aftercare involving the use of plastic surgery
V58.2 Blood transfusion, without reported diagnosis
V58.9 Unspecified aftercare
See Section IV.K. and Section IV.L. of the Outpatient guidelines.
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