Melanie Witt, RN, CPC, MA

Q An Ob patient presented to the emergency room (ER) in labor. The ER doctor immediately delivered the baby.

Labor and delivery staff had by then arrived. They took neonate and mom to the Ob suite, where I delivered the placenta and inspected and attended to the vagina.

The ER coded that their physician performed the “delivery,” using 59409 (Vaginal delivery only [with or without episiotomy and/or forceps]). They felt they would be out of compliance if they did not bill as such. I disagree. They took a large part of the Ob fee, and we were denied the payment for our complete obstetric care.

What should they have coded?

A The ER physician can certainly bill for delivering the baby, but this is not always done. Sometimes an agreement exists between the hospital and the attending physicians/Ob unit stating that any delivery performed by ER physicians will be billed by the attending obstetrician; compensation is then handled internally.

In this case, the ER physician may bill for delivery, but should have included modifier –52 to indicate a reduced service Code 59409 includes the delivery of the placenta (and episiotomy, if required), which the ER physician did not perform.

For your part, you have 2 coding options: You can bill for the global care, but add modifier -52 to 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps]). You’ll need to submit documentation indicating what part of the global care you did not perform. Here I would emphasize that the ER physician did not do labor management, delivery of the placenta, episiotomy, or any follow-up care—and that as such, the total amount for the delivery should not be deducted from your global fee.

Conversely, you can itemize the services you performed. This could consist of the following codes:

• 59426: seven or more antepartum visits (your fee will be the total for all visits)
  
• 9922X: hospital admission
  
• 59300: episiotomy repair (this code has 0 global days)
  
• 59414-51: delivery of placenta (again, 0 global days)
  
• 9923X: subsequent hospital care
  
• 99238: hospital discharge (if applicable)
  
• 59430: postpartum care (outpatient)
  

Q An Ob patient presented to the emergency room (ER) in labor. The ER doctor immediately delivered the baby.

Labor and delivery staff had by then arrived. They took neonate and mom to the Ob suite, where I delivered the placenta and inspected and attended to the vagina.

The ER coded that their physician performed the “delivery,” using 59409 (Vaginal delivery only [with or without episiotomy and/or forceps]). They felt they would be out of compliance if they did not bill as such. I disagree. They took a large part of the Ob fee, and we were denied the payment for our complete obstetric care.

What should they have coded?

A The ER physician can certainly bill for delivering the baby, but this is not always done. Sometimes an agreement exists between the hospital and the attending physicians/Ob unit stating that any delivery performed by ER physicians will be billed by the attending obstetrician; compensation is then handled internally.

In this case, the ER physician may bill for delivery, but should have included modifier –52 to indicate a reduced service Code 59409 includes the delivery of the placenta (and episiotomy, if required), which the ER physician did not perform.

For your part, you have 2 coding options: You can bill for the global care, but add modifier -52 to 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps]). You’ll need to submit documentation indicating what part of the global care you did not perform. Here I would emphasize that the ER physician did not do labor management, delivery of the placenta, episiotomy, or any follow-up care—and that as such, the total amount for the delivery should not be deducted from your global fee.

Conversely, you can itemize the services you performed. This could consist of the following codes:

• 59426: seven or more antepartum visits (your fee will be the total for all visits)
  
• 9922X: hospital admission
  
• 59300: episiotomy repair (this code has 0 global days)
  
• 59414-51: delivery of placenta (again, 0 global days)
  
• 9923X: subsequent hospital care
  
• 99238: hospital discharge (if applicable)
  
• 59430: postpartum care (outpatient)
  

Q An Ob patient presented to the emergency room (ER) in labor. The ER doctor immediately delivered the baby.

Labor and delivery staff had by then arrived. They took neonate and mom to the Ob suite, where I delivered the placenta and inspected and attended to the vagina.

The ER coded that their physician performed the “delivery,” using 59409 (Vaginal delivery only [with or without episiotomy and/or forceps]). They felt they would be out of compliance if they did not bill as such. I disagree. They took a large part of the Ob fee, and we were denied the payment for our complete obstetric care.

What should they have coded?

A The ER physician can certainly bill for delivering the baby, but this is not always done. Sometimes an agreement exists between the hospital and the attending physicians/Ob unit stating that any delivery performed by ER physicians will be billed by the attending obstetrician; compensation is then handled internally.

In this case, the ER physician may bill for delivery, but should have included modifier –52 to indicate a reduced service Code 59409 includes the delivery of the placenta (and episiotomy, if required), which the ER physician did not perform.

For your part, you have 2 coding options: You can bill for the global care, but add modifier -52 to 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps]). You’ll need to submit documentation indicating what part of the global care you did not perform. Here I would emphasize that the ER physician did not do labor management, delivery of the placenta, episiotomy, or any follow-up care—and that as such, the total amount for the delivery should not be deducted from your global fee.

Conversely, you can itemize the services you performed. This could consist of the following codes:

• 59426: seven or more antepartum visits (your fee will be the total for all visits)
  
• 9922X: hospital admission
  
• 59300: episiotomy repair (this code has 0 global days)
  
• 59414-51: delivery of placenta (again, 0 global days)
  
• 9923X: subsequent hospital care
  
• 99238: hospital discharge (if applicable)
  
• 59430: postpartum care (outpatient)
  

Q The American College of Obstetricians and Gynecologists instructs us to bill an evaluation and management (E/M) visit with the ICD-9 code for suppression of menses (626.8) if the Ob record is not initiated. I simply need to document the patient’s signs and symptoms; if I determine she’s pregnant, I can start the Ob record at her next visit.

My question is, what other services can I provide at this E/M visit? Can I order prenatal labs? Gyn probe? Prenatal vitamins? I don’t want to cross the line.

A According to ICD-9-CM rules, you must code what you know at the end of the visit. If a urine pregnancy test performed during the visit is positive before the patient leaves, the diagnosis code is V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy)—not suppressed menses. However, 626.8 can also be linked to both the pregnancy test procedure and the E/M service.

As to what else is allowed: You can perform any service that is not normally part of the Ob global package (meaning it can be billed separately).

Prescribing vitamins and ordering labs is permissible, since these are minor activities that do not impact the level of E/M service you bill.

The Gyn probe is questionable, since it is not done unless the patient is pregnant. However, since this is generally a separately billable service, the payer may allow it.

Just be sure you’re not counseling for the pregnancy or taking pregnancy measurements, and then coding a higher level of E/M service. Any payer will likely construe this as initiation of global care.

Q The American College of Obstetricians and Gynecologists instructs us to bill an evaluation and management (E/M) visit with the ICD-9 code for suppression of menses (626.8) if the Ob record is not initiated. I simply need to document the patient’s signs and symptoms; if I determine she’s pregnant, I can start the Ob record at her next visit.

My question is, what other services can I provide at this E/M visit? Can I order prenatal labs? Gyn probe? Prenatal vitamins? I don’t want to cross the line.

A According to ICD-9-CM rules, you must code what you know at the end of the visit. If a urine pregnancy test performed during the visit is positive before the patient leaves, the diagnosis code is V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy)—not suppressed menses. However, 626.8 can also be linked to both the pregnancy test procedure and the E/M service.

As to what else is allowed: You can perform any service that is not normally part of the Ob global package (meaning it can be billed separately).

Prescribing vitamins and ordering labs is permissible, since these are minor activities that do not impact the level of E/M service you bill.

The Gyn probe is questionable, since it is not done unless the patient is pregnant. However, since this is generally a separately billable service, the payer may allow it.

Just be sure you’re not counseling for the pregnancy or taking pregnancy measurements, and then coding a higher level of E/M service. Any payer will likely construe this as initiation of global care.

Q The American College of Obstetricians and Gynecologists instructs us to bill an evaluation and management (E/M) visit with the ICD-9 code for suppression of menses (626.8) if the Ob record is not initiated. I simply need to document the patient’s signs and symptoms; if I determine she’s pregnant, I can start the Ob record at her next visit.

My question is, what other services can I provide at this E/M visit? Can I order prenatal labs? Gyn probe? Prenatal vitamins? I don’t want to cross the line.

A According to ICD-9-CM rules, you must code what you know at the end of the visit. If a urine pregnancy test performed during the visit is positive before the patient leaves, the diagnosis code is V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy)—not suppressed menses. However, 626.8 can also be linked to both the pregnancy test procedure and the E/M service.

As to what else is allowed: You can perform any service that is not normally part of the Ob global package (meaning it can be billed separately).

Prescribing vitamins and ordering labs is permissible, since these are minor activities that do not impact the level of E/M service you bill.

The Gyn probe is questionable, since it is not done unless the patient is pregnant. However, since this is generally a separately billable service, the payer may allow it.

Just be sure you’re not counseling for the pregnancy or taking pregnancy measurements, and then coding a higher level of E/M service. Any payer will likely construe this as initiation of global care.

QCan I bill for placing an ON-Q device during surgery?

AThe ON-Q Elite (I-Flow Corporation, Lake Forest, Calif) is a system that automatically delivers local anesthesia into a surgical incision. It consists of a small electronic, reusable pump that has a single-use, disposable bag and tubing set to hold the anesthetic, plus a tiny tube to deliver it.

The only work required for this system is placing the tube into the incision site before closing. The company recommends using code 58999 (Unlisted procedure, female genital system [non-obstetrical], for placement of needles and catheters) for non-Ob procedures and 59899 (Unlisted procedure, maternity care and delivery) for obstetric surgery.

Reimbursement will depend on the payer’s policy regarding placing catheters during surgery: Many hold the opinion that this is incidental to the procedure. However, I’m told that on appeal Aetna, Avmed, and Cigna HMO have reimbursed for placing the catheter, but United and Blue Cross/Blue Shield have not.

You can also bill for the system itself if you—not the hospital—supplied it to the patient.

QCan I bill for placing an ON-Q device during surgery?

AThe ON-Q Elite (I-Flow Corporation, Lake Forest, Calif) is a system that automatically delivers local anesthesia into a surgical incision. It consists of a small electronic, reusable pump that has a single-use, disposable bag and tubing set to hold the anesthetic, plus a tiny tube to deliver it.

The only work required for this system is placing the tube into the incision site before closing. The company recommends using code 58999 (Unlisted procedure, female genital system [non-obstetrical], for placement of needles and catheters) for non-Ob procedures and 59899 (Unlisted procedure, maternity care and delivery) for obstetric surgery.

Reimbursement will depend on the payer’s policy regarding placing catheters during surgery: Many hold the opinion that this is incidental to the procedure. However, I’m told that on appeal Aetna, Avmed, and Cigna HMO have reimbursed for placing the catheter, but United and Blue Cross/Blue Shield have not.

You can also bill for the system itself if you—not the hospital—supplied it to the patient.

QCan I bill for placing an ON-Q device during surgery?

AThe ON-Q Elite (I-Flow Corporation, Lake Forest, Calif) is a system that automatically delivers local anesthesia into a surgical incision. It consists of a small electronic, reusable pump that has a single-use, disposable bag and tubing set to hold the anesthetic, plus a tiny tube to deliver it.

The only work required for this system is placing the tube into the incision site before closing. The company recommends using code 58999 (Unlisted procedure, female genital system [non-obstetrical], for placement of needles and catheters) for non-Ob procedures and 59899 (Unlisted procedure, maternity care and delivery) for obstetric surgery.

Reimbursement will depend on the payer’s policy regarding placing catheters during surgery: Many hold the opinion that this is incidental to the procedure. However, I’m told that on appeal Aetna, Avmed, and Cigna HMO have reimbursed for placing the catheter, but United and Blue Cross/Blue Shield have not.

You can also bill for the system itself if you—not the hospital—supplied it to the patient.

<huc>Q</huc> I’m trying to find out if Medicare will reimburse for intralesional injections into genital warts (CPT code 11900: Injection, skin intralesional, 1-7 lesions) with interferon alpha-n3.

When I looked this up under the heading “office injectable,” the Medicare carrier policy stated that a diagnosis of genital warts (078.10, Viral warts, unspecified; or 078.19, Viral warts, other specified) was allowed only when billed with intralesional administration of bleomycin.

Is this correct?

<huc>A</huc> This brings up an interesting question: How easy is it to zero in on the correct Medicare local medical policy review (LMPR)?

I’ve found I usually have to search their policy database (www.cms.hhs.gov/mcd/search.asp?) trying several different terms to get the results I need. I usually start with a term that is broad but specific, and then move to terms that are very specific.

Searching for code 11900 would produce too many hits; simply using the phrase “office injectable” is also not specific enough, since it implies intramuscular injections or supplied drugs. In this case, I started with “intralesional injection” and came up with 2 LMPRs. When I entered “interferon alfa-n3” I got 1 hit for Regence Blue Cross/Blue Shield, which indicates the injection is covered.

Following are the policies of 2 Medicare carriers (my notes appear in brackets). Based on these results, it looks like the injection should be covered:

• AdminaStar Federal policy. Intralesional injection of interferon alfa-n3 [coded using J9215] has been associated with complete or partial resolution of lesions associated with infection by HPV. It is currently indicated for the local treatment of Condylomata acuminate [coded as 078.11]. Coverage will be provided for those applications in which clinical utility has been demonstrated.
• Cahaba policy. Recombinant interferon alfa-2b, interferon alfa-n1 (1ns), and interferon alfa-n3 are indicated by intralesional injection for treatment of refractory or recurrent external condyloma acuminatum (genital warts).

<huc>Q</huc> I’m trying to find out if Medicare will reimburse for intralesional injections into genital warts (CPT code 11900: Injection, skin intralesional, 1-7 lesions) with interferon alpha-n3.

When I looked this up under the heading “office injectable,” the Medicare carrier policy stated that a diagnosis of genital warts (078.10, Viral warts, unspecified; or 078.19, Viral warts, other specified) was allowed only when billed with intralesional administration of bleomycin.

Is this correct?

<huc>A</huc> This brings up an interesting question: How easy is it to zero in on the correct Medicare local medical policy review (LMPR)?

I’ve found I usually have to search their policy database (www.cms.hhs.gov/mcd/search.asp?) trying several different terms to get the results I need. I usually start with a term that is broad but specific, and then move to terms that are very specific.

Searching for code 11900 would produce too many hits; simply using the phrase “office injectable” is also not specific enough, since it implies intramuscular injections or supplied drugs. In this case, I started with “intralesional injection” and came up with 2 LMPRs. When I entered “interferon alfa-n3” I got 1 hit for Regence Blue Cross/Blue Shield, which indicates the injection is covered.

Following are the policies of 2 Medicare carriers (my notes appear in brackets). Based on these results, it looks like the injection should be covered:

• AdminaStar Federal policy. Intralesional injection of interferon alfa-n3 [coded using J9215] has been associated with complete or partial resolution of lesions associated with infection by HPV. It is currently indicated for the local treatment of Condylomata acuminate [coded as 078.11]. Coverage will be provided for those applications in which clinical utility has been demonstrated.
• Cahaba policy. Recombinant interferon alfa-2b, interferon alfa-n1 (1ns), and interferon alfa-n3 are indicated by intralesional injection for treatment of refractory or recurrent external condyloma acuminatum (genital warts).

<huc>Q</huc> I’m trying to find out if Medicare will reimburse for intralesional injections into genital warts (CPT code 11900: Injection, skin intralesional, 1-7 lesions) with interferon alpha-n3.

When I looked this up under the heading “office injectable,” the Medicare carrier policy stated that a diagnosis of genital warts (078.10, Viral warts, unspecified; or 078.19, Viral warts, other specified) was allowed only when billed with intralesional administration of bleomycin.

Is this correct?

<huc>A</huc> This brings up an interesting question: How easy is it to zero in on the correct Medicare local medical policy review (LMPR)?

I’ve found I usually have to search their policy database (www.cms.hhs.gov/mcd/search.asp?) trying several different terms to get the results I need. I usually start with a term that is broad but specific, and then move to terms that are very specific.

Searching for code 11900 would produce too many hits; simply using the phrase “office injectable” is also not specific enough, since it implies intramuscular injections or supplied drugs. In this case, I started with “intralesional injection” and came up with 2 LMPRs. When I entered “interferon alfa-n3” I got 1 hit for Regence Blue Cross/Blue Shield, which indicates the injection is covered.

Following are the policies of 2 Medicare carriers (my notes appear in brackets). Based on these results, it looks like the injection should be covered:

• AdminaStar Federal policy. Intralesional injection of interferon alfa-n3 [coded using J9215] has been associated with complete or partial resolution of lesions associated with infection by HPV. It is currently indicated for the local treatment of Condylomata acuminate [coded as 078.11]. Coverage will be provided for those applications in which clinical utility has been demonstrated.
• Cahaba policy. Recombinant interferon alfa-2b, interferon alfa-n1 (1ns), and interferon alfa-n3 are indicated by intralesional injection for treatment of refractory or recurrent external condyloma acuminatum (genital warts).

Q A patient underwent a sling operation last year, but the mesh didn’t hold. She’s scheduled to have the eroded mesh replaced, but I can’t find a good diagnosis code.

A There actually is a very good diagnosis code: 996.76 (other complications of internal [biological] [synthetic] prosthetic device, implant, and graft; due to genitourinary device, implant, and graft). This is acceptable as the primary diagnosis. Use it in conjunction with CPT code 57287 (removal or revision of sling for stress incontinence [eg, fascia or synthetic]).

Q A patient underwent a sling operation last year, but the mesh didn’t hold. She’s scheduled to have the eroded mesh replaced, but I can’t find a good diagnosis code.

A There actually is a very good diagnosis code: 996.76 (other complications of internal [biological] [synthetic] prosthetic device, implant, and graft; due to genitourinary device, implant, and graft). This is acceptable as the primary diagnosis. Use it in conjunction with CPT code 57287 (removal or revision of sling for stress incontinence [eg, fascia or synthetic]).

Q A patient underwent a sling operation last year, but the mesh didn’t hold. She’s scheduled to have the eroded mesh replaced, but I can’t find a good diagnosis code.

A There actually is a very good diagnosis code: 996.76 (other complications of internal [biological] [synthetic] prosthetic device, implant, and graft; due to genitourinary device, implant, and graft). This is acceptable as the primary diagnosis. Use it in conjunction with CPT code 57287 (removal or revision of sling for stress incontinence [eg, fascia or synthetic]).

<huc>Q</huc> We received an error from an auditor regarding radiology readings for obstetric ultrasounds. We looked at the size and date of the fetus, and didn’t document a maternal evaluation (the cervix, however, was documented).

For transabdominal, we use 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal & maternal evaluation, first trimester [<14 weeks, 0 days], transabdominal approach; single or first gestation) or 76805 (…after first trimester [14 weeks 0 days]). The auditor tells us that, when the maternal evaluation isn’t documented, we should use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus)

My impression was that 76816 is for follow-up ultrasound only. When we requested clarification, the auditor replied that this code was for either assessment or reassessment.

<huc>A</huc> In this case, the auditor is not interpreting the follow-up code correctly. The nomenclature clearly states that 76816 is for a reevaluation, not an initial assessment.

The auditor is correct, however, that you have not documented all the required elements for the codes you are billing.

Maternal evaluation is required under both CPT and American College of Radiology/American Institute of Ultrasound in Medicine (ACR/AIUM) rules. To bill 76801, ACR/AIUM requires location and number of gestational sacs, crown-rump length, presence or absence of fetal life, evaluation of uterus (including cervix), and adnexa. The guidelines for code 76805 use similar language.

Your coding options will depend on the fetal gestation: If the fetus is less than 14 weeks, consider billing a limited ultrasound (76815: Ultrasound, pregnant uterus, real time with image documentation, limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) instead of 76801 when maternal structures are not documented. You could also add a “reduced services” modifier (-52) to the code.

Modifier -52 is an even better choice when the fetus is past 14 weeks, since fetal scrutiny is greater than it is for the younger fetus.

<huc>Q</huc> We received an error from an auditor regarding radiology readings for obstetric ultrasounds. We looked at the size and date of the fetus, and didn’t document a maternal evaluation (the cervix, however, was documented).

For transabdominal, we use 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal & maternal evaluation, first trimester [<14 weeks, 0 days], transabdominal approach; single or first gestation) or 76805 (…after first trimester [14 weeks 0 days]). The auditor tells us that, when the maternal evaluation isn’t documented, we should use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus)

My impression was that 76816 is for follow-up ultrasound only. When we requested clarification, the auditor replied that this code was for either assessment or reassessment.

<huc>A</huc> In this case, the auditor is not interpreting the follow-up code correctly. The nomenclature clearly states that 76816 is for a reevaluation, not an initial assessment.

The auditor is correct, however, that you have not documented all the required elements for the codes you are billing.

Maternal evaluation is required under both CPT and American College of Radiology/American Institute of Ultrasound in Medicine (ACR/AIUM) rules. To bill 76801, ACR/AIUM requires location and number of gestational sacs, crown-rump length, presence or absence of fetal life, evaluation of uterus (including cervix), and adnexa. The guidelines for code 76805 use similar language.

Your coding options will depend on the fetal gestation: If the fetus is less than 14 weeks, consider billing a limited ultrasound (76815: Ultrasound, pregnant uterus, real time with image documentation, limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) instead of 76801 when maternal structures are not documented. You could also add a “reduced services” modifier (-52) to the code.

Modifier -52 is an even better choice when the fetus is past 14 weeks, since fetal scrutiny is greater than it is for the younger fetus.

<huc>Q</huc> We received an error from an auditor regarding radiology readings for obstetric ultrasounds. We looked at the size and date of the fetus, and didn’t document a maternal evaluation (the cervix, however, was documented).

For transabdominal, we use 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal & maternal evaluation, first trimester [<14 weeks, 0 days], transabdominal approach; single or first gestation) or 76805 (…after first trimester [14 weeks 0 days]). The auditor tells us that, when the maternal evaluation isn’t documented, we should use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus)

My impression was that 76816 is for follow-up ultrasound only. When we requested clarification, the auditor replied that this code was for either assessment or reassessment.

<huc>A</huc> In this case, the auditor is not interpreting the follow-up code correctly. The nomenclature clearly states that 76816 is for a reevaluation, not an initial assessment.

The auditor is correct, however, that you have not documented all the required elements for the codes you are billing.

Maternal evaluation is required under both CPT and American College of Radiology/American Institute of Ultrasound in Medicine (ACR/AIUM) rules. To bill 76801, ACR/AIUM requires location and number of gestational sacs, crown-rump length, presence or absence of fetal life, evaluation of uterus (including cervix), and adnexa. The guidelines for code 76805 use similar language.

Your coding options will depend on the fetal gestation: If the fetus is less than 14 weeks, consider billing a limited ultrasound (76815: Ultrasound, pregnant uterus, real time with image documentation, limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) instead of 76801 when maternal structures are not documented. You could also add a “reduced services” modifier (-52) to the code.

Modifier -52 is an even better choice when the fetus is past 14 weeks, since fetal scrutiny is greater than it is for the younger fetus.

Q We are using a tampon coated with 5-fluorouracil (5-FU) cream (daily for 2 weeks) to treat a Medicare patient with highgrade vaginal lesion. Should we assign a low-level E/M code (it doesn’t take long) or is there a better procedure code?

A You will likely have trouble securing reimbursement because 5-FU can be self-administered via a vaginal applicator.

If this had been a 1-time treatment, I would advise using 57061 (destruction of vaginal lesion[s]; simple)—the lesion is being destroyed via chemosurgery. This code has a relative value unit of 3.01 when performed in the office. It is unlikely, however, that the Medicare carrier will reimburse for this level of procedure for 14 consecutive days, even if you use modifier -76 (repeat procedure by the same physician).

They might, however, allow you to bill a low-level E/M service each day, assuming you can get past the coverage guidelines for medications that can be self-administered. Are you, as the physician, personally inserting the tampon each time? If this is the case, and no other E/M services are taking place at each encounter, I would recommend billing a level 2 E/M service (99212) each day.

You might want to communicate with the carrier regarding why you are inserting the tampon rather than having the patient do it. For instance, is she unable to comply with the treatment because of age-related problems such as dexterity or senility?

Q We are using a tampon coated with 5-fluorouracil (5-FU) cream (daily for 2 weeks) to treat a Medicare patient with highgrade vaginal lesion. Should we assign a low-level E/M code (it doesn’t take long) or is there a better procedure code?

A You will likely have trouble securing reimbursement because 5-FU can be self-administered via a vaginal applicator.

If this had been a 1-time treatment, I would advise using 57061 (destruction of vaginal lesion[s]; simple)—the lesion is being destroyed via chemosurgery. This code has a relative value unit of 3.01 when performed in the office. It is unlikely, however, that the Medicare carrier will reimburse for this level of procedure for 14 consecutive days, even if you use modifier -76 (repeat procedure by the same physician).

They might, however, allow you to bill a low-level E/M service each day, assuming you can get past the coverage guidelines for medications that can be self-administered. Are you, as the physician, personally inserting the tampon each time? If this is the case, and no other E/M services are taking place at each encounter, I would recommend billing a level 2 E/M service (99212) each day.

You might want to communicate with the carrier regarding why you are inserting the tampon rather than having the patient do it. For instance, is she unable to comply with the treatment because of age-related problems such as dexterity or senility?

Q We are using a tampon coated with 5-fluorouracil (5-FU) cream (daily for 2 weeks) to treat a Medicare patient with highgrade vaginal lesion. Should we assign a low-level E/M code (it doesn’t take long) or is there a better procedure code?

A You will likely have trouble securing reimbursement because 5-FU can be self-administered via a vaginal applicator.

If this had been a 1-time treatment, I would advise using 57061 (destruction of vaginal lesion[s]; simple)—the lesion is being destroyed via chemosurgery. This code has a relative value unit of 3.01 when performed in the office. It is unlikely, however, that the Medicare carrier will reimburse for this level of procedure for 14 consecutive days, even if you use modifier -76 (repeat procedure by the same physician).

They might, however, allow you to bill a low-level E/M service each day, assuming you can get past the coverage guidelines for medications that can be self-administered. Are you, as the physician, personally inserting the tampon each time? If this is the case, and no other E/M services are taking place at each encounter, I would recommend billing a level 2 E/M service (99212) each day.

You might want to communicate with the carrier regarding why you are inserting the tampon rather than having the patient do it. For instance, is she unable to comply with the treatment because of age-related problems such as dexterity or senility?

<huc>Q</huc> I always have trouble getting insurers to pay for code 58611 (ligation or transection of fallopian tube[s] when done at the time of cesarean delivery or intra-abdominal surgery). The explanation of benefits (EOBs) states that an assistant is not required. Do you have any suggestions?

<huc>A</huc>ctually, there are 2 issues here: payment of a tubal ligation at the time of cesarean, and using an assistant during the ligation. You will probably have to appeal each case—unless you can persuade the payer to make a policy change.

The American College of Obstetricians and Gynecologists (ACOG) may be able to help with this. Its Committee on Coding and Nomenclature published 2 Committee Opinions on these topics.^1,2

In Tubal Ligation with Cesarean Delivery, ACOG states that tubal ligation is a distinct procedure with its own risks and liability; thus, it should be coded separately from the cesarean.¹ In the second opinion, Statement on Surgical Assistants, ACOG asserts that the surgeon’s judgment should dictate whether a surgical assistant is used; this should not be overruled by any third-party payers.²

The American College of Surgeons also published data on the need for an assistant for all procedures with CPT surgical codes. It determined that an assistant is “almost always required” when procedure 58611 is performed.³

From a coding perspective, the assistant would bill the “delivery-only code” for the cesarean—59514-80 (cesarean delivery only, assistant surgeon) or 59620-80 (cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, assistant surgeon)—along with 58611-80 for the ligation.

Note that 58611 is a CPT add-on code; it does not take a “multiple surgery” modifier because it can only be reported with a cesarean delivery code.

<huc>Q</huc> I always have trouble getting insurers to pay for code 58611 (ligation or transection of fallopian tube[s] when done at the time of cesarean delivery or intra-abdominal surgery). The explanation of benefits (EOBs) states that an assistant is not required. Do you have any suggestions?

<huc>A</huc>ctually, there are 2 issues here: payment of a tubal ligation at the time of cesarean, and using an assistant during the ligation. You will probably have to appeal each case—unless you can persuade the payer to make a policy change.

The American College of Obstetricians and Gynecologists (ACOG) may be able to help with this. Its Committee on Coding and Nomenclature published 2 Committee Opinions on these topics.^1,2

In Tubal Ligation with Cesarean Delivery, ACOG states that tubal ligation is a distinct procedure with its own risks and liability; thus, it should be coded separately from the cesarean.¹ In the second opinion, Statement on Surgical Assistants, ACOG asserts that the surgeon’s judgment should dictate whether a surgical assistant is used; this should not be overruled by any third-party payers.²

The American College of Surgeons also published data on the need for an assistant for all procedures with CPT surgical codes. It determined that an assistant is “almost always required” when procedure 58611 is performed.³

From a coding perspective, the assistant would bill the “delivery-only code” for the cesarean—59514-80 (cesarean delivery only, assistant surgeon) or 59620-80 (cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, assistant surgeon)—along with 58611-80 for the ligation.

Note that 58611 is a CPT add-on code; it does not take a “multiple surgery” modifier because it can only be reported with a cesarean delivery code.

<huc>Q</huc> I always have trouble getting insurers to pay for code 58611 (ligation or transection of fallopian tube[s] when done at the time of cesarean delivery or intra-abdominal surgery). The explanation of benefits (EOBs) states that an assistant is not required. Do you have any suggestions?

<huc>A</huc>ctually, there are 2 issues here: payment of a tubal ligation at the time of cesarean, and using an assistant during the ligation. You will probably have to appeal each case—unless you can persuade the payer to make a policy change.

The American College of Obstetricians and Gynecologists (ACOG) may be able to help with this. Its Committee on Coding and Nomenclature published 2 Committee Opinions on these topics.^1,2

In Tubal Ligation with Cesarean Delivery, ACOG states that tubal ligation is a distinct procedure with its own risks and liability; thus, it should be coded separately from the cesarean.¹ In the second opinion, Statement on Surgical Assistants, ACOG asserts that the surgeon’s judgment should dictate whether a surgical assistant is used; this should not be overruled by any third-party payers.²

The American College of Surgeons also published data on the need for an assistant for all procedures with CPT surgical codes. It determined that an assistant is “almost always required” when procedure 58611 is performed.³

From a coding perspective, the assistant would bill the “delivery-only code” for the cesarean—59514-80 (cesarean delivery only, assistant surgeon) or 59620-80 (cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, assistant surgeon)—along with 58611-80 for the ligation.

Note that 58611 is a CPT add-on code; it does not take a “multiple surgery” modifier because it can only be reported with a cesarean delivery code.

Q I gave misoprostol to a woman in prodromal labor who was a high-risk pregnancy (due to previous miscarriage and preterm labor that was successfully suppressed with bedrest and nifedipine). What would be the appropriate diagnosis for the misoprostol?

A The fact that this was a high-risk pregnancy has no bearing on the coding for the misoprostol administration. It is the prodromal labor—in which the early phase of labor is prolonged with contractions that do not increase in intensity—that is relevant.

The correct linking diagnosis is 662.0X (prolonged first stage of labor). If she was also preterm at this stage, you may indicate that as a secondary diagnosis.

Q I gave misoprostol to a woman in prodromal labor who was a high-risk pregnancy (due to previous miscarriage and preterm labor that was successfully suppressed with bedrest and nifedipine). What would be the appropriate diagnosis for the misoprostol?

A The fact that this was a high-risk pregnancy has no bearing on the coding for the misoprostol administration. It is the prodromal labor—in which the early phase of labor is prolonged with contractions that do not increase in intensity—that is relevant.

The correct linking diagnosis is 662.0X (prolonged first stage of labor). If she was also preterm at this stage, you may indicate that as a secondary diagnosis.

Q I gave misoprostol to a woman in prodromal labor who was a high-risk pregnancy (due to previous miscarriage and preterm labor that was successfully suppressed with bedrest and nifedipine). What would be the appropriate diagnosis for the misoprostol?

A The fact that this was a high-risk pregnancy has no bearing on the coding for the misoprostol administration. It is the prodromal labor—in which the early phase of labor is prolonged with contractions that do not increase in intensity—that is relevant.

The correct linking diagnosis is 662.0X (prolonged first stage of labor). If she was also preterm at this stage, you may indicate that as a secondary diagnosis.

Q What diagnosis code would I use for an abnormal quad test?

A The quad test is an “enhanced prenatal screening test” for Down syndrome, trisomy 18, and neural tube defects that is performed between the 15th and 20th week of gestation. It measures 4 substances in the mother’s blood that come from the developing fetus and placenta: alpha-fetoprotein, human chorionic gonadotropin (hCG), estriol, and inhibin-A (which is not included in the routine triple screen).

A positive result simply places the patient at higher risk for having a baby with one of the indicated conditions—it does not diagnose the child with anything. Unless the patient has a family history of Down syndrome or neural tube defects, the correct ICD-9 code is V28.8 (other antenatal screening). If there is a relevant family history, use V23.49 (pregnancy with other poor obstetric history) along with either V18.4 (family history of mental retardation) or V19.5 (family history of congenital anomalies).

For positive screening tests, use 655.13 (known or suspected chromosomal abnormality in fetus) or 796.5 (abnormal finding on antenatal screening), because you do not yet have a definitive diagnosis.

If a problem with the fetus is confirmed through additional testing, you will use the code for the diagnosed condition for the rest of the pregnancy.

Q What diagnosis code would I use for an abnormal quad test?

A The quad test is an “enhanced prenatal screening test” for Down syndrome, trisomy 18, and neural tube defects that is performed between the 15th and 20th week of gestation. It measures 4 substances in the mother’s blood that come from the developing fetus and placenta: alpha-fetoprotein, human chorionic gonadotropin (hCG), estriol, and inhibin-A (which is not included in the routine triple screen).

A positive result simply places the patient at higher risk for having a baby with one of the indicated conditions—it does not diagnose the child with anything. Unless the patient has a family history of Down syndrome or neural tube defects, the correct ICD-9 code is V28.8 (other antenatal screening). If there is a relevant family history, use V23.49 (pregnancy with other poor obstetric history) along with either V18.4 (family history of mental retardation) or V19.5 (family history of congenital anomalies).

For positive screening tests, use 655.13 (known or suspected chromosomal abnormality in fetus) or 796.5 (abnormal finding on antenatal screening), because you do not yet have a definitive diagnosis.

If a problem with the fetus is confirmed through additional testing, you will use the code for the diagnosed condition for the rest of the pregnancy.

Q What diagnosis code would I use for an abnormal quad test?

A The quad test is an “enhanced prenatal screening test” for Down syndrome, trisomy 18, and neural tube defects that is performed between the 15th and 20th week of gestation. It measures 4 substances in the mother’s blood that come from the developing fetus and placenta: alpha-fetoprotein, human chorionic gonadotropin (hCG), estriol, and inhibin-A (which is not included in the routine triple screen).

A positive result simply places the patient at higher risk for having a baby with one of the indicated conditions—it does not diagnose the child with anything. Unless the patient has a family history of Down syndrome or neural tube defects, the correct ICD-9 code is V28.8 (other antenatal screening). If there is a relevant family history, use V23.49 (pregnancy with other poor obstetric history) along with either V18.4 (family history of mental retardation) or V19.5 (family history of congenital anomalies).

For positive screening tests, use 655.13 (known or suspected chromosomal abnormality in fetus) or 796.5 (abnormal finding on antenatal screening), because you do not yet have a definitive diagnosis.

If a problem with the fetus is confirmed through additional testing, you will use the code for the diagnosed condition for the rest of the pregnancy.