Reimbursement Advisor

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

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.

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

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.

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

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.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

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.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

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.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

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.

Q A new doctor in our practice performed a minilaparotomy with ovarian cystectomy. Since none of our other physicians use this approach, I’m not sure how to code. Any pointers?

A It depends on what you mean by minilaparotomy. In some procedures the incision is small, but it is still an abdominal incision. In others, a “Hasson” or “open field” technique is used, with a small incision to direct the trocar into the correct position. In this case, CPT previously directed coders to add modifier –22 to the primary laparoscopic procedure. (These instructions appeared in CPT as a note before the laparoscopic procedures were distributed throughout the CPT book.)

However, if your physician always uses this technique for performing laparoscopy, the payer will ignore the –22 modifier.

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.

Q A new doctor in our practice performed a minilaparotomy with ovarian cystectomy. Since none of our other physicians use this approach, I’m not sure how to code. Any pointers?

A It depends on what you mean by minilaparotomy. In some procedures the incision is small, but it is still an abdominal incision. In others, a “Hasson” or “open field” technique is used, with a small incision to direct the trocar into the correct position. In this case, CPT previously directed coders to add modifier –22 to the primary laparoscopic procedure. (These instructions appeared in CPT as a note before the laparoscopic procedures were distributed throughout the CPT book.)

However, if your physician always uses this technique for performing laparoscopy, the payer will ignore the –22 modifier.

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.

Q A new doctor in our practice performed a minilaparotomy with ovarian cystectomy. Since none of our other physicians use this approach, I’m not sure how to code. Any pointers?

A It depends on what you mean by minilaparotomy. In some procedures the incision is small, but it is still an abdominal incision. In others, a “Hasson” or “open field” technique is used, with a small incision to direct the trocar into the correct position. In this case, CPT previously directed coders to add modifier –22 to the primary laparoscopic procedure. (These instructions appeared in CPT as a note before the laparoscopic procedures were distributed throughout the CPT book.)

However, if your physician always uses this technique for performing laparoscopy, the payer will ignore the –22 modifier.

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.

Q What code should I use for laparoscopic supracervical hysterectomy? Code 58180 appears to be intended for the abdominal approach.

A CPT rules clearly forbid billing a laparoscopic procedure using a code for the abdominal approach. This leaves you with 2 options: Either use

• existing laparoscopically assisted vaginal hysterectomy codes (58550– 58554) with modifier –52 added to denote a reduced service because the cervix was not removed, or
  
• unlisted laparoscopy code 58579.
  

ACOG is working on new codes for laparoscopic supracervical hysterectomy.

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.

Q What code should I use for laparoscopic supracervical hysterectomy? Code 58180 appears to be intended for the abdominal approach.

A CPT rules clearly forbid billing a laparoscopic procedure using a code for the abdominal approach. This leaves you with 2 options: Either use

• existing laparoscopically assisted vaginal hysterectomy codes (58550– 58554) with modifier –52 added to denote a reduced service because the cervix was not removed, or
  
• unlisted laparoscopy code 58579.
  

ACOG is working on new codes for laparoscopic supracervical hysterectomy.

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.

Q What code should I use for laparoscopic supracervical hysterectomy? Code 58180 appears to be intended for the abdominal approach.

A CPT rules clearly forbid billing a laparoscopic procedure using a code for the abdominal approach. This leaves you with 2 options: Either use

• existing laparoscopically assisted vaginal hysterectomy codes (58550– 58554) with modifier –52 added to denote a reduced service because the cervix was not removed, or
  
• unlisted laparoscopy code 58579.
  

ACOG is working on new codes for laparoscopic supracervical hysterectomy.

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.

Q A patient was admitted to a hospital at 37 weeks’ gestation for preterm labor. She stayed 15 days but did not deliver.

Can the attending physician charge outside the global fee for interpreting non-stress tests (NSTs) during this period? If so, how many readings a day can be billed?

A At 37 weeks, the patient does not have premature labor (644.0x), but “other threatened labor,” which is ICD-9 code 644.13 if she does not go on to deliver during this hospitalization. The physician can bill for the admission and daily rounding, but billing for the NST will depend on whether one was performed.

To bill for 59025, the patient is required to mark the strip to indicate fetal movements throughout the 30 to 40 minutes of the test. It would only be necessary to do so if the physician suspected a fetal problem.

However, if external fetal monitors are being used to count contractions or monitor heart rate, the NST would be billed as part of the exam.

No Limit on Number of Tests, If Medically Needed

If a true NST is performed and documented and the physician has interpreted the results, then the obstetrician can bill for it using 59025–59026. No protocols stipulate a limit for NSTs in a single day, but the payer will likely ask about medical necessity if more than 1 per day is performed—especially if the results are all reassuring and the patient is close to term.

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.

Q A patient was admitted to a hospital at 37 weeks’ gestation for preterm labor. She stayed 15 days but did not deliver.

Can the attending physician charge outside the global fee for interpreting non-stress tests (NSTs) during this period? If so, how many readings a day can be billed?

A At 37 weeks, the patient does not have premature labor (644.0x), but “other threatened labor,” which is ICD-9 code 644.13 if she does not go on to deliver during this hospitalization. The physician can bill for the admission and daily rounding, but billing for the NST will depend on whether one was performed.

To bill for 59025, the patient is required to mark the strip to indicate fetal movements throughout the 30 to 40 minutes of the test. It would only be necessary to do so if the physician suspected a fetal problem.

However, if external fetal monitors are being used to count contractions or monitor heart rate, the NST would be billed as part of the exam.

No Limit on Number of Tests, If Medically Needed

If a true NST is performed and documented and the physician has interpreted the results, then the obstetrician can bill for it using 59025–59026. No protocols stipulate a limit for NSTs in a single day, but the payer will likely ask about medical necessity if more than 1 per day is performed—especially if the results are all reassuring and the patient is close to term.

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.

Q A patient was admitted to a hospital at 37 weeks’ gestation for preterm labor. She stayed 15 days but did not deliver.

Can the attending physician charge outside the global fee for interpreting non-stress tests (NSTs) during this period? If so, how many readings a day can be billed?

A At 37 weeks, the patient does not have premature labor (644.0x), but “other threatened labor,” which is ICD-9 code 644.13 if she does not go on to deliver during this hospitalization. The physician can bill for the admission and daily rounding, but billing for the NST will depend on whether one was performed.

To bill for 59025, the patient is required to mark the strip to indicate fetal movements throughout the 30 to 40 minutes of the test. It would only be necessary to do so if the physician suspected a fetal problem.

However, if external fetal monitors are being used to count contractions or monitor heart rate, the NST would be billed as part of the exam.

No Limit on Number of Tests, If Medically Needed

If a true NST is performed and documented and the physician has interpreted the results, then the obstetrician can bill for it using 59025–59026. No protocols stipulate a limit for NSTs in a single day, but the payer will likely ask about medical necessity if more than 1 per day is performed—especially if the results are all reassuring and the patient is close to term.

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.

Q A patient was sent to a midwife by the physician managing her pregnancy. She was sent to obtain information on midwifery so she could decide whether to transfer care.

Can this visit be billed as a consultation, since the physician asked the midwife to see the patient?

A No. A consultation happens when a physician or other health-care professional asks a physician for an opinion or advice about the patient’s condition. Because a midwife has less training than a physician, a midwife is not allowed to bill for a consultation if asked to see a patient at an MD’s request. Remember, the idea behind the consult is to send the patient to someone with more expertise, not less.

It Was Counseling, Not Consulting

Further, the reason for the patient’s visit was not to seek the midwife’s opinion or advice about the patient’s condition. Rather, the midwife was asked to give the patient information, which is “counseling,” not “consulting.”

In this case, the payer may reimburse the midwife for an evaluation and management (E/M) service. Once the patient becomes an established patient for the pregnancy, the midwife will report the applicable maternity care code(s) for transfer of care for a portion of the pregnancy (eg, 59426 with 59410).

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.

Q A patient was sent to a midwife by the physician managing her pregnancy. She was sent to obtain information on midwifery so she could decide whether to transfer care.

Can this visit be billed as a consultation, since the physician asked the midwife to see the patient?

A No. A consultation happens when a physician or other health-care professional asks a physician for an opinion or advice about the patient’s condition. Because a midwife has less training than a physician, a midwife is not allowed to bill for a consultation if asked to see a patient at an MD’s request. Remember, the idea behind the consult is to send the patient to someone with more expertise, not less.

It Was Counseling, Not Consulting

Further, the reason for the patient’s visit was not to seek the midwife’s opinion or advice about the patient’s condition. Rather, the midwife was asked to give the patient information, which is “counseling,” not “consulting.”

In this case, the payer may reimburse the midwife for an evaluation and management (E/M) service. Once the patient becomes an established patient for the pregnancy, the midwife will report the applicable maternity care code(s) for transfer of care for a portion of the pregnancy (eg, 59426 with 59410).

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.

Q A patient was sent to a midwife by the physician managing her pregnancy. She was sent to obtain information on midwifery so she could decide whether to transfer care.

Can this visit be billed as a consultation, since the physician asked the midwife to see the patient?

A No. A consultation happens when a physician or other health-care professional asks a physician for an opinion or advice about the patient’s condition. Because a midwife has less training than a physician, a midwife is not allowed to bill for a consultation if asked to see a patient at an MD’s request. Remember, the idea behind the consult is to send the patient to someone with more expertise, not less.

It Was Counseling, Not Consulting

Further, the reason for the patient’s visit was not to seek the midwife’s opinion or advice about the patient’s condition. Rather, the midwife was asked to give the patient information, which is “counseling,” not “consulting.”

In this case, the payer may reimburse the midwife for an evaluation and management (E/M) service. Once the patient becomes an established patient for the pregnancy, the midwife will report the applicable maternity care code(s) for transfer of care for a portion of the pregnancy (eg, 59426 with 59410).

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.

Q When we bill for Pap tests (Q0091), vaginal cultures (87070), and stool guaiac (82270), insurance companies refuse to pay.

They tell me we can collect for obtaining the specimen, but I cannot find the correct CPT codes. How should I proceed?

A It depends on what payer you are billing and whether you have the correct Clinical Laboratories Improvement Act (CLIA) certificate to bill for laboratory procedures.

The code Q0091 was developed by Medicare to reimburse physicians for collecting a Pap smear at the time of an otherwise noncovered service. When they later added the code G0101 for the pelvic and breast exam portion of a preventive visit, they continued to reimburse for the collection as well.

Collection Codes

This collection code is not recognized by all payers, however. In fact, the American College of Obstetricians and Gynecologists (ACOG) has indicated that collection is part of the exam and not a separately billable service. However, some payers will allow you to collect for handling the specimen by using the code 99000.

Lab Codes

As for the lab tests you are billing, all providers are required to have the proper certificate before they can bill for laboratory tests. By billing the lab codes, you are telling the payer you are qualified to perform these tests and that you did, in fact, perform them. Once again, there is no collection code for either of these tests. Code 82270, which is a waived test, can be performed by the physician in the office, and the collection of the stool specimen is an integral part of the code. A waived test, by the way, still requires a certificate (visit www.cms.hhs.gov/clia/certypes.asp for definitions of the various certificate levels).

Culture Codes

The culture code you are using, 87070, is considered a highly complex test for which the highest certificate level would be required. Again, there is no collection code for the vaginal specimen, but you might be able to bill 99000 for the handling. If the Pap smear and culture collection are performed at the same visit, you would only bill 99000 once.

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.

Q When we bill for Pap tests (Q0091), vaginal cultures (87070), and stool guaiac (82270), insurance companies refuse to pay.

They tell me we can collect for obtaining the specimen, but I cannot find the correct CPT codes. How should I proceed?

A It depends on what payer you are billing and whether you have the correct Clinical Laboratories Improvement Act (CLIA) certificate to bill for laboratory procedures.

The code Q0091 was developed by Medicare to reimburse physicians for collecting a Pap smear at the time of an otherwise noncovered service. When they later added the code G0101 for the pelvic and breast exam portion of a preventive visit, they continued to reimburse for the collection as well.

Collection Codes

This collection code is not recognized by all payers, however. In fact, the American College of Obstetricians and Gynecologists (ACOG) has indicated that collection is part of the exam and not a separately billable service. However, some payers will allow you to collect for handling the specimen by using the code 99000.

Lab Codes

As for the lab tests you are billing, all providers are required to have the proper certificate before they can bill for laboratory tests. By billing the lab codes, you are telling the payer you are qualified to perform these tests and that you did, in fact, perform them. Once again, there is no collection code for either of these tests. Code 82270, which is a waived test, can be performed by the physician in the office, and the collection of the stool specimen is an integral part of the code. A waived test, by the way, still requires a certificate (visit www.cms.hhs.gov/clia/certypes.asp for definitions of the various certificate levels).

Culture Codes

The culture code you are using, 87070, is considered a highly complex test for which the highest certificate level would be required. Again, there is no collection code for the vaginal specimen, but you might be able to bill 99000 for the handling. If the Pap smear and culture collection are performed at the same visit, you would only bill 99000 once.

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.

Q When we bill for Pap tests (Q0091), vaginal cultures (87070), and stool guaiac (82270), insurance companies refuse to pay.

They tell me we can collect for obtaining the specimen, but I cannot find the correct CPT codes. How should I proceed?

A It depends on what payer you are billing and whether you have the correct Clinical Laboratories Improvement Act (CLIA) certificate to bill for laboratory procedures.

The code Q0091 was developed by Medicare to reimburse physicians for collecting a Pap smear at the time of an otherwise noncovered service. When they later added the code G0101 for the pelvic and breast exam portion of a preventive visit, they continued to reimburse for the collection as well.

Collection Codes

This collection code is not recognized by all payers, however. In fact, the American College of Obstetricians and Gynecologists (ACOG) has indicated that collection is part of the exam and not a separately billable service. However, some payers will allow you to collect for handling the specimen by using the code 99000.

Lab Codes

As for the lab tests you are billing, all providers are required to have the proper certificate before they can bill for laboratory tests. By billing the lab codes, you are telling the payer you are qualified to perform these tests and that you did, in fact, perform them. Once again, there is no collection code for either of these tests. Code 82270, which is a waived test, can be performed by the physician in the office, and the collection of the stool specimen is an integral part of the code. A waived test, by the way, still requires a certificate (visit www.cms.hhs.gov/clia/certypes.asp for definitions of the various certificate levels).

Culture Codes

The culture code you are using, 87070, is considered a highly complex test for which the highest certificate level would be required. Again, there is no collection code for the vaginal specimen, but you might be able to bill 99000 for the handling. If the Pap smear and culture collection are performed at the same visit, you would only bill 99000 once.

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.

Q When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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.

Q When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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.

Q When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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.

Q When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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.

Q When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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.

Q When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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.

Q I performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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.

Q I performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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.

Q I performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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.