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Correct coding when the patient goes to ER
Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.
The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).
If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.
The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).
If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.
The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).
If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
ICD code depends on why labor was induced
In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.
If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).
If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.
If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).
If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.
If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).
If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Use OB or GYN code if fetal pole is absent?
If the purpose of the ultrasound is only to check for fetal heart tones, then the correct code is 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).
While this scan could be performed transvaginally, the amount of work in checking only for fetal heart tones is significantly less than that involved in the OB transvaginal procedure.
Therefore, I recommend that you use the limited ultrasound code even if a vaginal probe was used.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
If the purpose of the ultrasound is only to check for fetal heart tones, then the correct code is 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).
While this scan could be performed transvaginally, the amount of work in checking only for fetal heart tones is significantly less than that involved in the OB transvaginal procedure.
Therefore, I recommend that you use the limited ultrasound code even if a vaginal probe was used.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
If the purpose of the ultrasound is only to check for fetal heart tones, then the correct code is 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).
While this scan could be performed transvaginally, the amount of work in checking only for fetal heart tones is significantly less than that involved in the OB transvaginal procedure.
Therefore, I recommend that you use the limited ultrasound code even if a vaginal probe was used.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
How do we code for new HPV vaccine?
- 90649 is the vaccine product code (human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use). A 3-dose schedule means you will be billing for the procedure 3 times during a 6-month period.
- 90471 can also be reported for the administration of the vaccine. (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid])
Adding modifiers. CPT guidelines state that a modifier -51 (multiple procedure) would not be added to either of these codes, and of course if you provide a significant and separate evaluation and management (E/M) service at the time the vaccine is given, you may also bill an E/M code with a modifier -25 added to let the payer know that the E/M service was separate.
Note that almost no payers will pay separately for the E/M code 99211 plus an injection procedure because it represents a minimal, not a significant E/M service.
Insurance coverage unlikely, for now
Until such time as the CDC comes out with a recommendation for the vaccine, coverage is going to be a problem. Insurance plans can be expected to cover the cost of the vaccine only if the CDC Advisory Committee on Immunization Practices recommends HPV vaccination as standard.
Tell patients! Until then, you may want to advise your patients who are candidates for the vaccine that this vaccine may be an out-of-pocket expense for them. Merck, the company that produces the quadrivalent vaccine, has stated that the price will be $120 per injection. The company has indicated that they have created a new program to provide free vaccines including HPV vaccine, for uninsured adults unable to pay.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
- 90649 is the vaccine product code (human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use). A 3-dose schedule means you will be billing for the procedure 3 times during a 6-month period.
- 90471 can also be reported for the administration of the vaccine. (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid])
Adding modifiers. CPT guidelines state that a modifier -51 (multiple procedure) would not be added to either of these codes, and of course if you provide a significant and separate evaluation and management (E/M) service at the time the vaccine is given, you may also bill an E/M code with a modifier -25 added to let the payer know that the E/M service was separate.
Note that almost no payers will pay separately for the E/M code 99211 plus an injection procedure because it represents a minimal, not a significant E/M service.
Insurance coverage unlikely, for now
Until such time as the CDC comes out with a recommendation for the vaccine, coverage is going to be a problem. Insurance plans can be expected to cover the cost of the vaccine only if the CDC Advisory Committee on Immunization Practices recommends HPV vaccination as standard.
Tell patients! Until then, you may want to advise your patients who are candidates for the vaccine that this vaccine may be an out-of-pocket expense for them. Merck, the company that produces the quadrivalent vaccine, has stated that the price will be $120 per injection. The company has indicated that they have created a new program to provide free vaccines including HPV vaccine, for uninsured adults unable to pay.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
- 90649 is the vaccine product code (human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use). A 3-dose schedule means you will be billing for the procedure 3 times during a 6-month period.
- 90471 can also be reported for the administration of the vaccine. (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid])
Adding modifiers. CPT guidelines state that a modifier -51 (multiple procedure) would not be added to either of these codes, and of course if you provide a significant and separate evaluation and management (E/M) service at the time the vaccine is given, you may also bill an E/M code with a modifier -25 added to let the payer know that the E/M service was separate.
Note that almost no payers will pay separately for the E/M code 99211 plus an injection procedure because it represents a minimal, not a significant E/M service.
Insurance coverage unlikely, for now
Until such time as the CDC comes out with a recommendation for the vaccine, coverage is going to be a problem. Insurance plans can be expected to cover the cost of the vaccine only if the CDC Advisory Committee on Immunization Practices recommends HPV vaccination as standard.
Tell patients! Until then, you may want to advise your patients who are candidates for the vaccine that this vaccine may be an out-of-pocket expense for them. Merck, the company that produces the quadrivalent vaccine, has stated that the price will be $120 per injection. The company has indicated that they have created a new program to provide free vaccines including HPV vaccine, for uninsured adults unable to pay.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
New 3D ultrasound codes are not for routine use
Payment for services during miscarriage
Induction with IV oxytocin would be classified as medical management of an abortion. Under CPT rules and ACOG guidelines, you would bill only for the evaluation and management (E/M) services. However, this means you would be billing for the hospital admission, subsequent care, and, prior to delivery, prolonged physician services. In this case you would report the hospital prolonged care codes that account for the actual time you spent with the patient managing her labor, as long as that time exceeds by 30 minutes the typical time of the E/M code you reported (TABLE).
For instance, if she is admitted at 10 PM on day 1 and delivers on day 2 at 2 PM, with your having documented that you spent a total of 2 hours at the patient’s bedside on day 1 and 8 hours at the patient’s bedside on day 2, you could bill as follows:
Day 1: Hospital admission (eg, 99222, requiring comprehensive history and exam and moderate medical decision-making with a typical time of 50 minutes)
Prolonged services on day 1: 120 minutes total –50 minutes=70 minutes of prolonged service. Bill code 99356 (first 60 minutes), but no additional code for the last 10 minutes of prolonged service.
Day 2: Subsequent hospital care (eg, 99232 requiring an expanded problem, focused history or exam with moderate complexity of medical decision-making with a typical time of 25 minutes).
Prolonged services for 8 hours on day 2: 480 minutes total –25 minutes=455 minutes of prolonged service; bill code 99356 (first 60 minutes), and 99357 with a quantity of 13 for the remaining 395 minutes.
TABLE
You have to do the math: Coding prolonged physician services
| TOTAL TIME W/PATIENT | BASIC SERVICE | BILLABLE PROLONGED SERVICE | PROLONGED SERVICES WITH CODES REPORTED |
|---|---|---|---|
| Day 1 120 minutes | 99222 (50 minutes) | 120 min –50 min=70 minutes | 99356 for first 60 minutes, but no extra codes for last 10 minutes |
| Day 2 480 minutes | 99232 (25 minutes) | 480 min –25 min=455 minutes | 99356 for first 60 minutes; 455 min –60 minutes=395 minutes 99357×13 for remaining time (13 times for each 30-minute increment) |
Induction with IV oxytocin would be classified as medical management of an abortion. Under CPT rules and ACOG guidelines, you would bill only for the evaluation and management (E/M) services. However, this means you would be billing for the hospital admission, subsequent care, and, prior to delivery, prolonged physician services. In this case you would report the hospital prolonged care codes that account for the actual time you spent with the patient managing her labor, as long as that time exceeds by 30 minutes the typical time of the E/M code you reported (TABLE).
For instance, if she is admitted at 10 PM on day 1 and delivers on day 2 at 2 PM, with your having documented that you spent a total of 2 hours at the patient’s bedside on day 1 and 8 hours at the patient’s bedside on day 2, you could bill as follows:
Day 1: Hospital admission (eg, 99222, requiring comprehensive history and exam and moderate medical decision-making with a typical time of 50 minutes)
Prolonged services on day 1: 120 minutes total –50 minutes=70 minutes of prolonged service. Bill code 99356 (first 60 minutes), but no additional code for the last 10 minutes of prolonged service.
Day 2: Subsequent hospital care (eg, 99232 requiring an expanded problem, focused history or exam with moderate complexity of medical decision-making with a typical time of 25 minutes).
Prolonged services for 8 hours on day 2: 480 minutes total –25 minutes=455 minutes of prolonged service; bill code 99356 (first 60 minutes), and 99357 with a quantity of 13 for the remaining 395 minutes.
TABLE
You have to do the math: Coding prolonged physician services
| TOTAL TIME W/PATIENT | BASIC SERVICE | BILLABLE PROLONGED SERVICE | PROLONGED SERVICES WITH CODES REPORTED |
|---|---|---|---|
| Day 1 120 minutes | 99222 (50 minutes) | 120 min –50 min=70 minutes | 99356 for first 60 minutes, but no extra codes for last 10 minutes |
| Day 2 480 minutes | 99232 (25 minutes) | 480 min –25 min=455 minutes | 99356 for first 60 minutes; 455 min –60 minutes=395 minutes 99357×13 for remaining time (13 times for each 30-minute increment) |
Induction with IV oxytocin would be classified as medical management of an abortion. Under CPT rules and ACOG guidelines, you would bill only for the evaluation and management (E/M) services. However, this means you would be billing for the hospital admission, subsequent care, and, prior to delivery, prolonged physician services. In this case you would report the hospital prolonged care codes that account for the actual time you spent with the patient managing her labor, as long as that time exceeds by 30 minutes the typical time of the E/M code you reported (TABLE).
For instance, if she is admitted at 10 PM on day 1 and delivers on day 2 at 2 PM, with your having documented that you spent a total of 2 hours at the patient’s bedside on day 1 and 8 hours at the patient’s bedside on day 2, you could bill as follows:
Day 1: Hospital admission (eg, 99222, requiring comprehensive history and exam and moderate medical decision-making with a typical time of 50 minutes)
Prolonged services on day 1: 120 minutes total –50 minutes=70 minutes of prolonged service. Bill code 99356 (first 60 minutes), but no additional code for the last 10 minutes of prolonged service.
Day 2: Subsequent hospital care (eg, 99232 requiring an expanded problem, focused history or exam with moderate complexity of medical decision-making with a typical time of 25 minutes).
Prolonged services for 8 hours on day 2: 480 minutes total –25 minutes=455 minutes of prolonged service; bill code 99356 (first 60 minutes), and 99357 with a quantity of 13 for the remaining 395 minutes.
TABLE
You have to do the math: Coding prolonged physician services
| TOTAL TIME W/PATIENT | BASIC SERVICE | BILLABLE PROLONGED SERVICE | PROLONGED SERVICES WITH CODES REPORTED |
|---|---|---|---|
| Day 1 120 minutes | 99222 (50 minutes) | 120 min –50 min=70 minutes | 99356 for first 60 minutes, but no extra codes for last 10 minutes |
| Day 2 480 minutes | 99232 (25 minutes) | 480 min –25 min=455 minutes | 99356 for first 60 minutes; 455 min –60 minutes=395 minutes 99357×13 for remaining time (13 times for each 30-minute increment) |
Getting paid for pregnancy complications
Would it be appropriate to add a –57 modifier (decision to do surgery) to the admission, and if so, what modifier should be added to subsequent hospital visits?
But some payers will acknowledge that the patient is being treated for a complication of the pregnancy and not for admission for delivery and will allow both the admission and any subsequent visits except on the day of delivery.
The problem with any modifier prior to delivery with global obstetric care is that “delivery” is the inevitable outcome of the care, so the modifier –57, in my opinion, is not appropriate in this setting for the physician who is providing the global care. If the MFM specialist has not been providing maternity care and then determines that an emergency delivery must be performed, modifier –57 might be warranted. There are no other applicable modifiers for the care prior to delivery.
I suggest that you appeal the denial. Explain that the admission was not planned, and the reason for admission and care on the second day was for a complication of pregnancy, not labor management.
Would it be appropriate to add a –57 modifier (decision to do surgery) to the admission, and if so, what modifier should be added to subsequent hospital visits?
But some payers will acknowledge that the patient is being treated for a complication of the pregnancy and not for admission for delivery and will allow both the admission and any subsequent visits except on the day of delivery.
The problem with any modifier prior to delivery with global obstetric care is that “delivery” is the inevitable outcome of the care, so the modifier –57, in my opinion, is not appropriate in this setting for the physician who is providing the global care. If the MFM specialist has not been providing maternity care and then determines that an emergency delivery must be performed, modifier –57 might be warranted. There are no other applicable modifiers for the care prior to delivery.
I suggest that you appeal the denial. Explain that the admission was not planned, and the reason for admission and care on the second day was for a complication of pregnancy, not labor management.
Would it be appropriate to add a –57 modifier (decision to do surgery) to the admission, and if so, what modifier should be added to subsequent hospital visits?
But some payers will acknowledge that the patient is being treated for a complication of the pregnancy and not for admission for delivery and will allow both the admission and any subsequent visits except on the day of delivery.
The problem with any modifier prior to delivery with global obstetric care is that “delivery” is the inevitable outcome of the care, so the modifier –57, in my opinion, is not appropriate in this setting for the physician who is providing the global care. If the MFM specialist has not been providing maternity care and then determines that an emergency delivery must be performed, modifier –57 might be warranted. There are no other applicable modifiers for the care prior to delivery.
I suggest that you appeal the denial. Explain that the admission was not planned, and the reason for admission and care on the second day was for a complication of pregnancy, not labor management.
Code for perineoplasty depends on setting
If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.
If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.
If a repair only is documented, your other possibility is to use codes 12001–12004 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less up to 12.5 cm). These codes do have a practice expense differential when the procedure is carried out in the office. Like the perineoplasty code, this code series has a 10-day global period.
Don’t fail to dispute inappropriate bundling
I have appealed many times, but they refuse to pay for both. Do you have any suggestions?
The payer is not correct in this case. Medicare rules stipulate that a consultation can be billed with a diagnostic procedure on the same day and both will be paid. You should ask for the exact reference to the Medicare rule they are using.
In addition, I suggest that you add a modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code you are billing. This tactic will clearly identify the E/M service as significant and separate from the diagnostic test.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
I have appealed many times, but they refuse to pay for both. Do you have any suggestions?
The payer is not correct in this case. Medicare rules stipulate that a consultation can be billed with a diagnostic procedure on the same day and both will be paid. You should ask for the exact reference to the Medicare rule they are using.
In addition, I suggest that you add a modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code you are billing. This tactic will clearly identify the E/M service as significant and separate from the diagnostic test.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
I have appealed many times, but they refuse to pay for both. Do you have any suggestions?
The payer is not correct in this case. Medicare rules stipulate that a consultation can be billed with a diagnostic procedure on the same day and both will be paid. You should ask for the exact reference to the Medicare rule they are using.
In addition, I suggest that you add a modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the consultation code you are billing. This tactic will clearly identify the E/M service as significant and separate from the diagnostic test.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Payers discourage multiple sonograms
Transvaginal ultrasound
This procedure is included as part of 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed). Transvaginal ultrasound should not be billed in addition unless it was performed to document a problem not related to the hysterosonogram. The ACOG coding manual agrees; it indicates that a transvaginal ultrasound should not be reported separately because it is included in the global service when performed. Since the Correct Coding Initiative (CCI) also bundles this code combination, you could bill it only if it was done during a separate session. A modifier -59 (Distinct procedural service) would be added to 76831 because this procedure is bundled into the code for the transvaginal ultrasound.
3D ultrasound
Your second coding problem is performing a 3D ultrasound at the time of the hysterosonogram. Here, there are 2 issues: insurance coverage and billing.
Many payers do not reimburse for 3D ultrasound because they consider it experimental—and none reimburse 3D ultrasound when done routinely. Medical necessity must be established for 3D rendering. Be sure to inform your patients that this procedure may not be covered by their insurance company, so that they can make an informed choice.
Billing
The CPT code you indicated, 76375, has been replaced by 2 new codes:
- Code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation) and
- Code 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation).
CPT does not stipulate which codes can serve as the basic scan, but as 76831 is an ultrasound procedure, the payer may allow it to be used in this fashion.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Transvaginal ultrasound
This procedure is included as part of 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed). Transvaginal ultrasound should not be billed in addition unless it was performed to document a problem not related to the hysterosonogram. The ACOG coding manual agrees; it indicates that a transvaginal ultrasound should not be reported separately because it is included in the global service when performed. Since the Correct Coding Initiative (CCI) also bundles this code combination, you could bill it only if it was done during a separate session. A modifier -59 (Distinct procedural service) would be added to 76831 because this procedure is bundled into the code for the transvaginal ultrasound.
3D ultrasound
Your second coding problem is performing a 3D ultrasound at the time of the hysterosonogram. Here, there are 2 issues: insurance coverage and billing.
Many payers do not reimburse for 3D ultrasound because they consider it experimental—and none reimburse 3D ultrasound when done routinely. Medical necessity must be established for 3D rendering. Be sure to inform your patients that this procedure may not be covered by their insurance company, so that they can make an informed choice.
Billing
The CPT code you indicated, 76375, has been replaced by 2 new codes:
- Code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation) and
- Code 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation).
CPT does not stipulate which codes can serve as the basic scan, but as 76831 is an ultrasound procedure, the payer may allow it to be used in this fashion.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Transvaginal ultrasound
This procedure is included as part of 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed). Transvaginal ultrasound should not be billed in addition unless it was performed to document a problem not related to the hysterosonogram. The ACOG coding manual agrees; it indicates that a transvaginal ultrasound should not be reported separately because it is included in the global service when performed. Since the Correct Coding Initiative (CCI) also bundles this code combination, you could bill it only if it was done during a separate session. A modifier -59 (Distinct procedural service) would be added to 76831 because this procedure is bundled into the code for the transvaginal ultrasound.
3D ultrasound
Your second coding problem is performing a 3D ultrasound at the time of the hysterosonogram. Here, there are 2 issues: insurance coverage and billing.
Many payers do not reimburse for 3D ultrasound because they consider it experimental—and none reimburse 3D ultrasound when done routinely. Medical necessity must be established for 3D rendering. Be sure to inform your patients that this procedure may not be covered by their insurance company, so that they can make an informed choice.
Billing
The CPT code you indicated, 76375, has been replaced by 2 new codes:
- Code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation) and
- Code 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation).
CPT does not stipulate which codes can serve as the basic scan, but as 76831 is an ultrasound procedure, the payer may allow it to be used in this fashion.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.