Reimbursement Advisor

1All vaginal vault suspensions can be coded

The American College of Obstetricians and Gynecologists (ACOG) requested new codes to address the various techniques of vaginal vault suspension. Until this year, only 1 vaginal colpopexy code was available: sacrospinous ligament fixation. For any other type of suspension, we had to bill for the procedure using either the unlisted code 58999 or the code that was closest, 57282 (sacrospinous ligament fixation for prolapse of vagina).

As of January 1, the 2 code revisions, 57282 and 57283, will address any suspension technique (TABLE). Which you choose will depend on whether the suspension occurs outside the peritoneal cavity (by attaching it to the iliococcygeus muscle or sacrospinous ligament), or inside (using the uterosacral ligament or performing a high midline levator myorrhaphy).

Note that the code for the intraperitoneal approach cannot be billed with code 58263 (vaginal hysterectomy with bilateral salpingo-oophorectomy and enterocele repair).

Mesh augmentation

A new code was created for mesh augmentation, when the patient’s tissue is weak or inadequate for cystocele, rectocele, or enterocele repair. Code 57267 is an “add-on” code, meaning it is never used without an additional “base” code. It is billed with 45560 (rectocele repair), 57240 (anterior colporrhaphy), 57250 (posterior colporrhaphy), 57260 (combined anterior and posterior repair), or 57265 (combined anterior and posterior repair with enterocele repair).

Note that the code’s description indicates “each site.” Thus, if mesh is required in both the anterior and posterior compartments, code 57267 is listed twice.

2Cryoablation promoted from “developing technology”

Now rescued from Category III (temporary code 0009T), endometrial cryoablation has its own code, 58356, in the surgery section.

You should not bill separately for endometrial biopsy (58100), dilation and curettage (58120), saline-infusion sonogram/hysterosalpingogram (58340), abdominal ultrasound (76700), or pelvic ultrasound (76856); all are included in 58356. Note that the nomenclature states that ultrasound guidance is also included.

3Less hassle for less-invasive sterilization

Hysteroscopic sterilization (Essure; Conceptus, San Carlos, Calif)—which requires no abdominal incisions and can be performed in an office setting—now has its own code, 58565. Previously, the Healthcare Common Procedure Coding System (HCPCS) code S2555 and the code for an unlisted hysteroscopy (58579) were used to fill this coding gap. Physician practices will be happy to note that this code was given 57.77 relative value units (RVUs) when performed in a nonfacility setting—enough to cover the cost of the implants.

Do not report this with diagnostic hysteroscopy (58555) and/or dilation of cervix (57800). Since the code is valued as a bilateral procedure, add a modifier -52 (reduced services) if the device is placed unilaterally.

4More options for fetal Doppler

The addition of 2 codes for fetal Doppler of the umbilical and middle cerebral arteries (76820 and 76821) is most welcome for maternal-fetal medicine specialists evaluating fetal anemia and fetal growth restriction. Until now, these 2 scans were reported using the Doppler echocardiography codes 76827 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete) or 76828 (Doppler echocardiography, … ; follow-up or repeat study).

 

Still no uterine artery Doppler code

For this, ACOG recommends continuing to use codes 76827 or 76828—but a closer code might be 93976 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study).

Note the slight change in nomenclature for 76827. The phrase “cardiovascular system” was removed for CPT 2005.

ULTRASOUNDNew requirement: Images must be recorded

Most noteworthy of the new ultrasound guidelines is the requirement that an image be recorded. Permanently recorded images with measurements are required for all diagnostic ultrasound examinations (when such measurements are clinically indicated).

Ultrasound guidance procedures also require permanently recorded images of the site to be localized, and a documented description of the localization process, either separately or within the procedure report for which the guidance is utilized. A final, written report should be placed in the patient’s medical record.

For anatomic regions that have “complete” and “limited” ultrasound codes:

• Note the elements that comprise a “complete” exam, and include in the report a description of each or the reason an element could not be visualized.
  
• Use the “limited” code—once per patient exam session—if reporting less than the required elements for a complete exam (eg, limited number of organs or limited portion of region evaluated).
  
• Do not report a “limited” exam for the same exam session as a “complete” exam of that same region.
  

Doppler evaluation of vascular structures (other than color flow used only for anatomic structure identification) is separately reportable.

Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report is not separately reportable.

Nonobstetric ultrasound

When to code complete ultrasound. The code for complete nonobstetric ultrasound (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) encompasses the comprehensive evaluation of the female pelvic anatomy, including:

• measurement of uterus and adnexal structures
  
• measurement of the endometrium
  
• measurement of the bladder (when applicable)
  
• description of any pelvic pathology
  

When to code limited ultrasound. The code for limited nonobstetric ultrasound (76857, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [eg, for follicles]) represents:

• focused examination limited to the assessment of 1 or more elements listed in code 76856, and/or
  
• reevaluation of 1 or more pelvic abnormalities previously seen on ultrasound.
  

Use this code when imaging the urinary bladder alone (not kidneys). If you measure bladder or postvoid residual volume at the same time as the bladder ultrasound, code 51798 (postvoid residual urine and/or bladder capacity by ultrasound, non-imaging) is not added.

ALSO NOTABLETotal omentectomy

Previously, no code existed to describe removal of the uterus and omentum for malignancy without lymph-node dissection. But when omental metastasis is present, pelvic and paraaortic lymph node dissection for staging is not usually necessary, since the disease has already spread into the abdominal cavity. New code 58956 addresses this problem. To report this code, the documentation must clearly indicate a total omentectomy (removal of both the lesser and greater omentum, also referred to as a supracolic omentectomy).

Debridement of genitalia

Three codes address debridement of the external genitalia and perineum skin for necrotizing soft tissue infection.

Screening for chromosome abnormalities

A new laboratory services code, 84163, describes the pregnancy-associated plasma protein-A (PAPP-A) screening test, used to identify women at highest risk of carrying a fetus with Down Syndrome, trisomy 18, or other chromosomal abnormality.

Oocyte storage

A revision to make “oocyte” plural in code 89346 (storage [per year]; oocytes) clarifies that each oocyte stored is not coded separately.

New appendices

Appendix F lists codes exempt from modifier -63 (Procedure performed on infants less than 4 kg).

Appendix G lists procedures that include conscious sedation. A new symbol, ••, was created to denote this for the individual codes included in this section. The only Ob/Gyn-specific code that carries this symbol is 58823 (drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [eg, ovarian, pericolic]).

Appendix H is an alphabetic index of Category II code performance measures (the index lists them by clinical condition or topic), and includes a brief description of the performance measure and its source.

Appendix I lists genetic testing code modifiers. Report these with the molecular lab procedures related to genetic testing. The modifiers are categorized by mutation: The first digit indicates the disease category, the second denotes the gene type. For instance, 0A signifies testing for the BRCA1 gene.

1All vaginal vault suspensions can be coded

The American College of Obstetricians and Gynecologists (ACOG) requested new codes to address the various techniques of vaginal vault suspension. Until this year, only 1 vaginal colpopexy code was available: sacrospinous ligament fixation. For any other type of suspension, we had to bill for the procedure using either the unlisted code 58999 or the code that was closest, 57282 (sacrospinous ligament fixation for prolapse of vagina).

As of January 1, the 2 code revisions, 57282 and 57283, will address any suspension technique (TABLE). Which you choose will depend on whether the suspension occurs outside the peritoneal cavity (by attaching it to the iliococcygeus muscle or sacrospinous ligament), or inside (using the uterosacral ligament or performing a high midline levator myorrhaphy).

Note that the code for the intraperitoneal approach cannot be billed with code 58263 (vaginal hysterectomy with bilateral salpingo-oophorectomy and enterocele repair).

Mesh augmentation

A new code was created for mesh augmentation, when the patient’s tissue is weak or inadequate for cystocele, rectocele, or enterocele repair. Code 57267 is an “add-on” code, meaning it is never used without an additional “base” code. It is billed with 45560 (rectocele repair), 57240 (anterior colporrhaphy), 57250 (posterior colporrhaphy), 57260 (combined anterior and posterior repair), or 57265 (combined anterior and posterior repair with enterocele repair).

Note that the code’s description indicates “each site.” Thus, if mesh is required in both the anterior and posterior compartments, code 57267 is listed twice.

2Cryoablation promoted from “developing technology”

Now rescued from Category III (temporary code 0009T), endometrial cryoablation has its own code, 58356, in the surgery section.

You should not bill separately for endometrial biopsy (58100), dilation and curettage (58120), saline-infusion sonogram/hysterosalpingogram (58340), abdominal ultrasound (76700), or pelvic ultrasound (76856); all are included in 58356. Note that the nomenclature states that ultrasound guidance is also included.

3Less hassle for less-invasive sterilization

Hysteroscopic sterilization (Essure; Conceptus, San Carlos, Calif)—which requires no abdominal incisions and can be performed in an office setting—now has its own code, 58565. Previously, the Healthcare Common Procedure Coding System (HCPCS) code S2555 and the code for an unlisted hysteroscopy (58579) were used to fill this coding gap. Physician practices will be happy to note that this code was given 57.77 relative value units (RVUs) when performed in a nonfacility setting—enough to cover the cost of the implants.

Do not report this with diagnostic hysteroscopy (58555) and/or dilation of cervix (57800). Since the code is valued as a bilateral procedure, add a modifier -52 (reduced services) if the device is placed unilaterally.

4More options for fetal Doppler

The addition of 2 codes for fetal Doppler of the umbilical and middle cerebral arteries (76820 and 76821) is most welcome for maternal-fetal medicine specialists evaluating fetal anemia and fetal growth restriction. Until now, these 2 scans were reported using the Doppler echocardiography codes 76827 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete) or 76828 (Doppler echocardiography, … ; follow-up or repeat study).

 

Still no uterine artery Doppler code

For this, ACOG recommends continuing to use codes 76827 or 76828—but a closer code might be 93976 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study).

Note the slight change in nomenclature for 76827. The phrase “cardiovascular system” was removed for CPT 2005.

ULTRASOUNDNew requirement: Images must be recorded

Most noteworthy of the new ultrasound guidelines is the requirement that an image be recorded. Permanently recorded images with measurements are required for all diagnostic ultrasound examinations (when such measurements are clinically indicated).

Ultrasound guidance procedures also require permanently recorded images of the site to be localized, and a documented description of the localization process, either separately or within the procedure report for which the guidance is utilized. A final, written report should be placed in the patient’s medical record.

For anatomic regions that have “complete” and “limited” ultrasound codes:

• Note the elements that comprise a “complete” exam, and include in the report a description of each or the reason an element could not be visualized.
  
• Use the “limited” code—once per patient exam session—if reporting less than the required elements for a complete exam (eg, limited number of organs or limited portion of region evaluated).
  
• Do not report a “limited” exam for the same exam session as a “complete” exam of that same region.
  

Doppler evaluation of vascular structures (other than color flow used only for anatomic structure identification) is separately reportable.

Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report is not separately reportable.

Nonobstetric ultrasound

When to code complete ultrasound. The code for complete nonobstetric ultrasound (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) encompasses the comprehensive evaluation of the female pelvic anatomy, including:

• measurement of uterus and adnexal structures
  
• measurement of the endometrium
  
• measurement of the bladder (when applicable)
  
• description of any pelvic pathology
  

When to code limited ultrasound. The code for limited nonobstetric ultrasound (76857, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [eg, for follicles]) represents:

• focused examination limited to the assessment of 1 or more elements listed in code 76856, and/or
  
• reevaluation of 1 or more pelvic abnormalities previously seen on ultrasound.
  

Use this code when imaging the urinary bladder alone (not kidneys). If you measure bladder or postvoid residual volume at the same time as the bladder ultrasound, code 51798 (postvoid residual urine and/or bladder capacity by ultrasound, non-imaging) is not added.

ALSO NOTABLETotal omentectomy

Previously, no code existed to describe removal of the uterus and omentum for malignancy without lymph-node dissection. But when omental metastasis is present, pelvic and paraaortic lymph node dissection for staging is not usually necessary, since the disease has already spread into the abdominal cavity. New code 58956 addresses this problem. To report this code, the documentation must clearly indicate a total omentectomy (removal of both the lesser and greater omentum, also referred to as a supracolic omentectomy).

Debridement of genitalia

Three codes address debridement of the external genitalia and perineum skin for necrotizing soft tissue infection.

Screening for chromosome abnormalities

A new laboratory services code, 84163, describes the pregnancy-associated plasma protein-A (PAPP-A) screening test, used to identify women at highest risk of carrying a fetus with Down Syndrome, trisomy 18, or other chromosomal abnormality.

Oocyte storage

A revision to make “oocyte” plural in code 89346 (storage [per year]; oocytes) clarifies that each oocyte stored is not coded separately.

New appendices

Appendix F lists codes exempt from modifier -63 (Procedure performed on infants less than 4 kg).

Appendix G lists procedures that include conscious sedation. A new symbol, ••, was created to denote this for the individual codes included in this section. The only Ob/Gyn-specific code that carries this symbol is 58823 (drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [eg, ovarian, pericolic]).

Appendix H is an alphabetic index of Category II code performance measures (the index lists them by clinical condition or topic), and includes a brief description of the performance measure and its source.

Appendix I lists genetic testing code modifiers. Report these with the molecular lab procedures related to genetic testing. The modifiers are categorized by mutation: The first digit indicates the disease category, the second denotes the gene type. For instance, 0A signifies testing for the BRCA1 gene.

1All vaginal vault suspensions can be coded

The American College of Obstetricians and Gynecologists (ACOG) requested new codes to address the various techniques of vaginal vault suspension. Until this year, only 1 vaginal colpopexy code was available: sacrospinous ligament fixation. For any other type of suspension, we had to bill for the procedure using either the unlisted code 58999 or the code that was closest, 57282 (sacrospinous ligament fixation for prolapse of vagina).

As of January 1, the 2 code revisions, 57282 and 57283, will address any suspension technique (TABLE). Which you choose will depend on whether the suspension occurs outside the peritoneal cavity (by attaching it to the iliococcygeus muscle or sacrospinous ligament), or inside (using the uterosacral ligament or performing a high midline levator myorrhaphy).

Note that the code for the intraperitoneal approach cannot be billed with code 58263 (vaginal hysterectomy with bilateral salpingo-oophorectomy and enterocele repair).

Mesh augmentation

A new code was created for mesh augmentation, when the patient’s tissue is weak or inadequate for cystocele, rectocele, or enterocele repair. Code 57267 is an “add-on” code, meaning it is never used without an additional “base” code. It is billed with 45560 (rectocele repair), 57240 (anterior colporrhaphy), 57250 (posterior colporrhaphy), 57260 (combined anterior and posterior repair), or 57265 (combined anterior and posterior repair with enterocele repair).

Note that the code’s description indicates “each site.” Thus, if mesh is required in both the anterior and posterior compartments, code 57267 is listed twice.

2Cryoablation promoted from “developing technology”

Now rescued from Category III (temporary code 0009T), endometrial cryoablation has its own code, 58356, in the surgery section.

You should not bill separately for endometrial biopsy (58100), dilation and curettage (58120), saline-infusion sonogram/hysterosalpingogram (58340), abdominal ultrasound (76700), or pelvic ultrasound (76856); all are included in 58356. Note that the nomenclature states that ultrasound guidance is also included.

3Less hassle for less-invasive sterilization

Hysteroscopic sterilization (Essure; Conceptus, San Carlos, Calif)—which requires no abdominal incisions and can be performed in an office setting—now has its own code, 58565. Previously, the Healthcare Common Procedure Coding System (HCPCS) code S2555 and the code for an unlisted hysteroscopy (58579) were used to fill this coding gap. Physician practices will be happy to note that this code was given 57.77 relative value units (RVUs) when performed in a nonfacility setting—enough to cover the cost of the implants.

Do not report this with diagnostic hysteroscopy (58555) and/or dilation of cervix (57800). Since the code is valued as a bilateral procedure, add a modifier -52 (reduced services) if the device is placed unilaterally.

4More options for fetal Doppler

The addition of 2 codes for fetal Doppler of the umbilical and middle cerebral arteries (76820 and 76821) is most welcome for maternal-fetal medicine specialists evaluating fetal anemia and fetal growth restriction. Until now, these 2 scans were reported using the Doppler echocardiography codes 76827 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete) or 76828 (Doppler echocardiography, … ; follow-up or repeat study).

 

Still no uterine artery Doppler code

For this, ACOG recommends continuing to use codes 76827 or 76828—but a closer code might be 93976 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study).

Note the slight change in nomenclature for 76827. The phrase “cardiovascular system” was removed for CPT 2005.

ULTRASOUNDNew requirement: Images must be recorded

Most noteworthy of the new ultrasound guidelines is the requirement that an image be recorded. Permanently recorded images with measurements are required for all diagnostic ultrasound examinations (when such measurements are clinically indicated).

Ultrasound guidance procedures also require permanently recorded images of the site to be localized, and a documented description of the localization process, either separately or within the procedure report for which the guidance is utilized. A final, written report should be placed in the patient’s medical record.

For anatomic regions that have “complete” and “limited” ultrasound codes:

• Note the elements that comprise a “complete” exam, and include in the report a description of each or the reason an element could not be visualized.
  
• Use the “limited” code—once per patient exam session—if reporting less than the required elements for a complete exam (eg, limited number of organs or limited portion of region evaluated).
  
• Do not report a “limited” exam for the same exam session as a “complete” exam of that same region.
  

Doppler evaluation of vascular structures (other than color flow used only for anatomic structure identification) is separately reportable.

Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report is not separately reportable.

Nonobstetric ultrasound

When to code complete ultrasound. The code for complete nonobstetric ultrasound (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) encompasses the comprehensive evaluation of the female pelvic anatomy, including:

• measurement of uterus and adnexal structures
  
• measurement of the endometrium
  
• measurement of the bladder (when applicable)
  
• description of any pelvic pathology
  

When to code limited ultrasound. The code for limited nonobstetric ultrasound (76857, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [eg, for follicles]) represents:

• focused examination limited to the assessment of 1 or more elements listed in code 76856, and/or
  
• reevaluation of 1 or more pelvic abnormalities previously seen on ultrasound.
  

Use this code when imaging the urinary bladder alone (not kidneys). If you measure bladder or postvoid residual volume at the same time as the bladder ultrasound, code 51798 (postvoid residual urine and/or bladder capacity by ultrasound, non-imaging) is not added.

ALSO NOTABLETotal omentectomy

Previously, no code existed to describe removal of the uterus and omentum for malignancy without lymph-node dissection. But when omental metastasis is present, pelvic and paraaortic lymph node dissection for staging is not usually necessary, since the disease has already spread into the abdominal cavity. New code 58956 addresses this problem. To report this code, the documentation must clearly indicate a total omentectomy (removal of both the lesser and greater omentum, also referred to as a supracolic omentectomy).

Debridement of genitalia

Three codes address debridement of the external genitalia and perineum skin for necrotizing soft tissue infection.

Screening for chromosome abnormalities

A new laboratory services code, 84163, describes the pregnancy-associated plasma protein-A (PAPP-A) screening test, used to identify women at highest risk of carrying a fetus with Down Syndrome, trisomy 18, or other chromosomal abnormality.

Oocyte storage

A revision to make “oocyte” plural in code 89346 (storage [per year]; oocytes) clarifies that each oocyte stored is not coded separately.

New appendices

Appendix F lists codes exempt from modifier -63 (Procedure performed on infants less than 4 kg).

Appendix G lists procedures that include conscious sedation. A new symbol, ••, was created to denote this for the individual codes included in this section. The only Ob/Gyn-specific code that carries this symbol is 58823 (drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [eg, ovarian, pericolic]).

Appendix H is an alphabetic index of Category II code performance measures (the index lists them by clinical condition or topic), and includes a brief description of the performance measure and its source.

Appendix I lists genetic testing code modifiers. Report these with the molecular lab procedures related to genetic testing. The modifiers are categorized by mutation: The first digit indicates the disease category, the second denotes the gene type. For instance, 0A signifies testing for the BRCA1 gene.

Mrs. Smith undergoes a screening Pap smear at her annual exam. It has been several years since her last Pap test. The report indicates atypical glandular cells, favor neoplastic. You ask her to return for further testing. The coding dilemma: Should you report this as cancer in situ (233.1) or atypical cells of undetermined significance “favor dysplasia” (795.02)?

Thanks to the newly revised Pap smear section of the International Classification of Diseases–9th Revision–Clinical Modification (ICD-9-CM), frustrating scenarios like the one above are now a thing of the past.

The updated Pap codes are the most welcome changes to ICD-9 for 2005, but they’re not the only revisions that will ease coding difficulties in the coming year. A clip-and-save chart details the changes most relevant to Ob/Gyn practice.

Reporting Pap smear results

The ambiguous nature of Pap smear coding in recent years stemmed from some unfortunate timing: In October 2001, the codes for abnormal Pap smear (795.0X) were revised to correspond to Bethesda system findings, reported by more than 90% of US laboratories. Just before this revision was implemented, however, the Bethesda Committee revised its terminology, so the new codes no longer matched.

The codes now reflect the hierarchy of conditions as described by Bethesda. Thus, reference to “favor benign” and “favor dysplasia” were removed.

Category 795 was changed to “Other and nonspecific abnormal cytological, histological, immunological and DNA test findings.” Next, the heading for code 795.0 was changed to allow coding for both an abnormal Pap smear and cervical human papillomavirus (HPV).

New codes were added to report findings of a high-grade squamous intraepithelial lesion (HGSIL) and low-grade squamous intraepithelial lesion (LGSIL), and to differentiate between these results from a Pap smear specimen and histologic confirmation of dysplasia from a tissue biopsy.

A few notes:

• Glandular cell changes are now coded to 795.00. This includes a “favor neoplastic” finding, which solves the dilemma posed by the case example.
  
• Unsatisfactory or inadequate smear, previously coded with 795.09, is now 795.08.
  
• Code 795.09 is now used when a DNA test indicates a low risk for HPV (HPV types 6 and 11)
  
• When reporting 795.05 or 795.09, use an additional code for the associated HPV (079.4).
  

Why these revisions were crucial. Without a code for “atypical squamous cells–cannot rule out high-grade squamous intraepithelial lesions” (ASC-H) versus “atypical squamous cells–undetermined significance” (ASC-US), it was difficult to establish the medical need for HPV tests. The American Society for Colposcopy and Cervical Pathology recommends HPV testing for ASC-US, but not for ASC-H, which should proceed to follow-up colposcopy.

The revision also clarifies that category 795 diagnostic codes are not used for cervical intraepithelial neoplasia (CIN) or dysplasia pathology results.

CIN or dysplasia

For tissue biopsy pathology results indicating CIN 3 or severe dysplasia of the cervix, use code 233.1. For CIN 1 or 2 or mild to moderate dysplasia, use one of the expanded dysplasia codes from the 622.1 series.

Remember: The dysplasia codes are reported as a result of histologic confirmation; codes 795.00 to 795.09 involve a cytologic examination only.

Genital prolapse: more detail on the cause

Previously, code 618.0 covered a range of conditions, from cystocele to vaginal prolapse. However, since CPT is more specific about the various prolapse-repair procedures, ACOG requested an expansion of this code to provide additional detail.

Note, also, that a new code for overflow incontinence, 788.38, was added.

Female genital mutilation

A new subcategory—629.2, female genital mutilation (FGM) status—includes codes representing the range of FGM procedures, from partial clitoris amputation to the procedure known as infibulation.

Use these codes for a primary diagnosis in a nonpregnant patient seeking treatment to correct the mutilation, or as a secondary diagnosis when the patient is currently pregnant, or to medically justify cesarean delivery or a complicated vaginal delivery.

Endometrial hyperplasia

Code 621.3, previously used to report endometrial cystic hyperplasia, has been expanded to 4 new codes.

Peripartum cardiomyopathy

Code 648.6X (other cardiovascular diseases) now specifically excludes peripartum cardiomyopathy, which is coded 674.5X.

Diabetes mellitus

Diabetes is no longer termed insulin-dependent and non–insulin-dependent, but rather type I or type II (differentiated by the functioning of pancreatic beta cells, not by insulin use). Thus, the fifth-digit subclassification used with the diabetes codes in category 250 was revised as follows:

• 0–type II or unspecified type, not stated as uncontrolled
  
• 1–type I (juvenile type), not stated as uncontrolled
  
• 2–type II or unspecified type, uncontrolled
  
• 3–type I (juvenile type), uncontrolled
  

 

Report fifth-digits 0 and 2 even if the patient requires insulin—in which case, you may also report the new code V58.67 (long-term current use of insulin). This can be used as a secondary diagnosis, or as a primary diagnosis when the patient is seen for possible long-term effects rather than diabetic control. (Long-term current use of aspirin was also given a code, V58.66.)

V code changes Gynecologic exam

Per ACOG’s request, V72.3 has been expanded into 2 codes:

V72.31 covers routine gynecologic examination—including a Pap smear, if performed. Thus, do not report V76.2 (special screening for malignant neoplasms, cervix) with V72.31 for the exam. Note, however, that if the patient’s cervix is absent and a vaginal Pap smear is collected at the time of the visit, code V76.47 (routine vaginal Pap smear) is also needed.

V72.32 describes a repeat Pap smear in the following scenario: A patient has an abnormal Pap test and is brought back 3 months later for a follow-up Pap. (The diagnosis for that visit is the abnormal result.) The results come back normal and she is asked to return in a few months. You will use V72.32 for this last encounter.

ACOG clarifies V72.32 may be used more than once at the physician’s discretion, since the usual protocol is to perform more frequent Pap smears until obtaining 3 consecutive negative results. Caveat: Check with your Medicare carrier before using this code for the repeat Pap smears.

Pregnancy tests

With the expansion of V72.4, ICD-9 now has an option for a pregnancy test done prior to a procedure that may harm a fetus, or simply because you suspect pregnancy:

Use V72.40 when you perform a pregnancy test, but have not determined whether the patient is pregnant by the end of the visit (ie, a blood rather than urine test). Note that if the pregnancy test is positive, also report code V22.X, per ICD-9 guidelines. This pregnancy diagnosis can be linked to the CPT pregnancy test code.

Use V72.41 if you confirm she is not pregnant during this visit. (Again, if the test is positive, use code V22.X.)

Hormone replacement therapy

The term “postmenopausal” was moved to a parenthetical note for code V07.4, to denote that this code should be reported anytime a woman is placed on estrogen replacement therapy. ICD-9 also has clarified that it is not appropriate to use V58.69 (long-term [current] use of other high-risk medications) for patients on hormone replacement therapy—instead, select code V07.4.

Screening for osteoporosis

ICD-9 has clarified that code V07.4 should be reported with the code for osteoporosis screening (V82.81), if applicable.

Genetic susceptibility to disease

A new category addresses prophylactic organ removal. Until now, ICD-9 had codes to indicate that an encounter was for organ removal, but not to describe the reason for the removal.

Further, these codes were needed because the “carrier status” codes can be used only when the patient is a disease carrier, able to pass it to offspring—not when she herself is at risk.

Note that before you can use these codes, the patient’s record should show an abnormal gene confirmed by genetic test.

Acquired absence of organ

ICD-9 has clarified that code V45.77 (acquired absence of genital organs), excludes the new FGM status codes (629.20 to 629.23).

Exposure to communicable diseases

The American Academy of Pediatrics requested the addition of exposure codes to viral and other communicable diseases. Most important to Ob/Gyns is exposure to chickenpox (varicella), if the mother was not previously exposed. This new code, V01.71, may be enough to support the medical necessity for laboratory work to test for immunity to chickenpox.

Report code V01.79 for exposure to other viral diseases.

Lack of adequate sleep

New code V69.4 is reported for sleep deprivation, but excludes insomnia.

Mrs. Smith undergoes a screening Pap smear at her annual exam. It has been several years since her last Pap test. The report indicates atypical glandular cells, favor neoplastic. You ask her to return for further testing. The coding dilemma: Should you report this as cancer in situ (233.1) or atypical cells of undetermined significance “favor dysplasia” (795.02)?

Thanks to the newly revised Pap smear section of the International Classification of Diseases–9th Revision–Clinical Modification (ICD-9-CM), frustrating scenarios like the one above are now a thing of the past.

The updated Pap codes are the most welcome changes to ICD-9 for 2005, but they’re not the only revisions that will ease coding difficulties in the coming year. A clip-and-save chart details the changes most relevant to Ob/Gyn practice.

Reporting Pap smear results

The ambiguous nature of Pap smear coding in recent years stemmed from some unfortunate timing: In October 2001, the codes for abnormal Pap smear (795.0X) were revised to correspond to Bethesda system findings, reported by more than 90% of US laboratories. Just before this revision was implemented, however, the Bethesda Committee revised its terminology, so the new codes no longer matched.

The codes now reflect the hierarchy of conditions as described by Bethesda. Thus, reference to “favor benign” and “favor dysplasia” were removed.

Category 795 was changed to “Other and nonspecific abnormal cytological, histological, immunological and DNA test findings.” Next, the heading for code 795.0 was changed to allow coding for both an abnormal Pap smear and cervical human papillomavirus (HPV).

New codes were added to report findings of a high-grade squamous intraepithelial lesion (HGSIL) and low-grade squamous intraepithelial lesion (LGSIL), and to differentiate between these results from a Pap smear specimen and histologic confirmation of dysplasia from a tissue biopsy.

A few notes:

• Glandular cell changes are now coded to 795.00. This includes a “favor neoplastic” finding, which solves the dilemma posed by the case example.
  
• Unsatisfactory or inadequate smear, previously coded with 795.09, is now 795.08.
  
• Code 795.09 is now used when a DNA test indicates a low risk for HPV (HPV types 6 and 11)
  
• When reporting 795.05 or 795.09, use an additional code for the associated HPV (079.4).
  

Why these revisions were crucial. Without a code for “atypical squamous cells–cannot rule out high-grade squamous intraepithelial lesions” (ASC-H) versus “atypical squamous cells–undetermined significance” (ASC-US), it was difficult to establish the medical need for HPV tests. The American Society for Colposcopy and Cervical Pathology recommends HPV testing for ASC-US, but not for ASC-H, which should proceed to follow-up colposcopy.

The revision also clarifies that category 795 diagnostic codes are not used for cervical intraepithelial neoplasia (CIN) or dysplasia pathology results.

CIN or dysplasia

For tissue biopsy pathology results indicating CIN 3 or severe dysplasia of the cervix, use code 233.1. For CIN 1 or 2 or mild to moderate dysplasia, use one of the expanded dysplasia codes from the 622.1 series.

Remember: The dysplasia codes are reported as a result of histologic confirmation; codes 795.00 to 795.09 involve a cytologic examination only.

Genital prolapse: more detail on the cause

Previously, code 618.0 covered a range of conditions, from cystocele to vaginal prolapse. However, since CPT is more specific about the various prolapse-repair procedures, ACOG requested an expansion of this code to provide additional detail.

Note, also, that a new code for overflow incontinence, 788.38, was added.

Female genital mutilation

A new subcategory—629.2, female genital mutilation (FGM) status—includes codes representing the range of FGM procedures, from partial clitoris amputation to the procedure known as infibulation.

Use these codes for a primary diagnosis in a nonpregnant patient seeking treatment to correct the mutilation, or as a secondary diagnosis when the patient is currently pregnant, or to medically justify cesarean delivery or a complicated vaginal delivery.

Endometrial hyperplasia

Code 621.3, previously used to report endometrial cystic hyperplasia, has been expanded to 4 new codes.

Peripartum cardiomyopathy

Code 648.6X (other cardiovascular diseases) now specifically excludes peripartum cardiomyopathy, which is coded 674.5X.

Diabetes mellitus

Diabetes is no longer termed insulin-dependent and non–insulin-dependent, but rather type I or type II (differentiated by the functioning of pancreatic beta cells, not by insulin use). Thus, the fifth-digit subclassification used with the diabetes codes in category 250 was revised as follows:

• 0–type II or unspecified type, not stated as uncontrolled
  
• 1–type I (juvenile type), not stated as uncontrolled
  
• 2–type II or unspecified type, uncontrolled
  
• 3–type I (juvenile type), uncontrolled
  

 

Report fifth-digits 0 and 2 even if the patient requires insulin—in which case, you may also report the new code V58.67 (long-term current use of insulin). This can be used as a secondary diagnosis, or as a primary diagnosis when the patient is seen for possible long-term effects rather than diabetic control. (Long-term current use of aspirin was also given a code, V58.66.)

V code changes Gynecologic exam

Per ACOG’s request, V72.3 has been expanded into 2 codes:

V72.31 covers routine gynecologic examination—including a Pap smear, if performed. Thus, do not report V76.2 (special screening for malignant neoplasms, cervix) with V72.31 for the exam. Note, however, that if the patient’s cervix is absent and a vaginal Pap smear is collected at the time of the visit, code V76.47 (routine vaginal Pap smear) is also needed.

V72.32 describes a repeat Pap smear in the following scenario: A patient has an abnormal Pap test and is brought back 3 months later for a follow-up Pap. (The diagnosis for that visit is the abnormal result.) The results come back normal and she is asked to return in a few months. You will use V72.32 for this last encounter.

ACOG clarifies V72.32 may be used more than once at the physician’s discretion, since the usual protocol is to perform more frequent Pap smears until obtaining 3 consecutive negative results. Caveat: Check with your Medicare carrier before using this code for the repeat Pap smears.

Pregnancy tests

With the expansion of V72.4, ICD-9 now has an option for a pregnancy test done prior to a procedure that may harm a fetus, or simply because you suspect pregnancy:

Use V72.40 when you perform a pregnancy test, but have not determined whether the patient is pregnant by the end of the visit (ie, a blood rather than urine test). Note that if the pregnancy test is positive, also report code V22.X, per ICD-9 guidelines. This pregnancy diagnosis can be linked to the CPT pregnancy test code.

Use V72.41 if you confirm she is not pregnant during this visit. (Again, if the test is positive, use code V22.X.)

Hormone replacement therapy

The term “postmenopausal” was moved to a parenthetical note for code V07.4, to denote that this code should be reported anytime a woman is placed on estrogen replacement therapy. ICD-9 also has clarified that it is not appropriate to use V58.69 (long-term [current] use of other high-risk medications) for patients on hormone replacement therapy—instead, select code V07.4.

Screening for osteoporosis

ICD-9 has clarified that code V07.4 should be reported with the code for osteoporosis screening (V82.81), if applicable.

Genetic susceptibility to disease

A new category addresses prophylactic organ removal. Until now, ICD-9 had codes to indicate that an encounter was for organ removal, but not to describe the reason for the removal.

Further, these codes were needed because the “carrier status” codes can be used only when the patient is a disease carrier, able to pass it to offspring—not when she herself is at risk.

Note that before you can use these codes, the patient’s record should show an abnormal gene confirmed by genetic test.

Acquired absence of organ

ICD-9 has clarified that code V45.77 (acquired absence of genital organs), excludes the new FGM status codes (629.20 to 629.23).

Exposure to communicable diseases

The American Academy of Pediatrics requested the addition of exposure codes to viral and other communicable diseases. Most important to Ob/Gyns is exposure to chickenpox (varicella), if the mother was not previously exposed. This new code, V01.71, may be enough to support the medical necessity for laboratory work to test for immunity to chickenpox.

Report code V01.79 for exposure to other viral diseases.

Lack of adequate sleep

New code V69.4 is reported for sleep deprivation, but excludes insomnia.

Mrs. Smith undergoes a screening Pap smear at her annual exam. It has been several years since her last Pap test. The report indicates atypical glandular cells, favor neoplastic. You ask her to return for further testing. The coding dilemma: Should you report this as cancer in situ (233.1) or atypical cells of undetermined significance “favor dysplasia” (795.02)?

Thanks to the newly revised Pap smear section of the International Classification of Diseases–9th Revision–Clinical Modification (ICD-9-CM), frustrating scenarios like the one above are now a thing of the past.

The updated Pap codes are the most welcome changes to ICD-9 for 2005, but they’re not the only revisions that will ease coding difficulties in the coming year. A clip-and-save chart details the changes most relevant to Ob/Gyn practice.

Reporting Pap smear results

The ambiguous nature of Pap smear coding in recent years stemmed from some unfortunate timing: In October 2001, the codes for abnormal Pap smear (795.0X) were revised to correspond to Bethesda system findings, reported by more than 90% of US laboratories. Just before this revision was implemented, however, the Bethesda Committee revised its terminology, so the new codes no longer matched.

The codes now reflect the hierarchy of conditions as described by Bethesda. Thus, reference to “favor benign” and “favor dysplasia” were removed.

Category 795 was changed to “Other and nonspecific abnormal cytological, histological, immunological and DNA test findings.” Next, the heading for code 795.0 was changed to allow coding for both an abnormal Pap smear and cervical human papillomavirus (HPV).

New codes were added to report findings of a high-grade squamous intraepithelial lesion (HGSIL) and low-grade squamous intraepithelial lesion (LGSIL), and to differentiate between these results from a Pap smear specimen and histologic confirmation of dysplasia from a tissue biopsy.

A few notes:

• Glandular cell changes are now coded to 795.00. This includes a “favor neoplastic” finding, which solves the dilemma posed by the case example.
  
• Unsatisfactory or inadequate smear, previously coded with 795.09, is now 795.08.
  
• Code 795.09 is now used when a DNA test indicates a low risk for HPV (HPV types 6 and 11)
  
• When reporting 795.05 or 795.09, use an additional code for the associated HPV (079.4).
  

Why these revisions were crucial. Without a code for “atypical squamous cells–cannot rule out high-grade squamous intraepithelial lesions” (ASC-H) versus “atypical squamous cells–undetermined significance” (ASC-US), it was difficult to establish the medical need for HPV tests. The American Society for Colposcopy and Cervical Pathology recommends HPV testing for ASC-US, but not for ASC-H, which should proceed to follow-up colposcopy.

The revision also clarifies that category 795 diagnostic codes are not used for cervical intraepithelial neoplasia (CIN) or dysplasia pathology results.

CIN or dysplasia

For tissue biopsy pathology results indicating CIN 3 or severe dysplasia of the cervix, use code 233.1. For CIN 1 or 2 or mild to moderate dysplasia, use one of the expanded dysplasia codes from the 622.1 series.

Remember: The dysplasia codes are reported as a result of histologic confirmation; codes 795.00 to 795.09 involve a cytologic examination only.

Genital prolapse: more detail on the cause

Previously, code 618.0 covered a range of conditions, from cystocele to vaginal prolapse. However, since CPT is more specific about the various prolapse-repair procedures, ACOG requested an expansion of this code to provide additional detail.

Note, also, that a new code for overflow incontinence, 788.38, was added.

Female genital mutilation

A new subcategory—629.2, female genital mutilation (FGM) status—includes codes representing the range of FGM procedures, from partial clitoris amputation to the procedure known as infibulation.

Use these codes for a primary diagnosis in a nonpregnant patient seeking treatment to correct the mutilation, or as a secondary diagnosis when the patient is currently pregnant, or to medically justify cesarean delivery or a complicated vaginal delivery.

Endometrial hyperplasia

Code 621.3, previously used to report endometrial cystic hyperplasia, has been expanded to 4 new codes.

Peripartum cardiomyopathy

Code 648.6X (other cardiovascular diseases) now specifically excludes peripartum cardiomyopathy, which is coded 674.5X.

Diabetes mellitus

Diabetes is no longer termed insulin-dependent and non–insulin-dependent, but rather type I or type II (differentiated by the functioning of pancreatic beta cells, not by insulin use). Thus, the fifth-digit subclassification used with the diabetes codes in category 250 was revised as follows:

• 0–type II or unspecified type, not stated as uncontrolled
  
• 1–type I (juvenile type), not stated as uncontrolled
  
• 2–type II or unspecified type, uncontrolled
  
• 3–type I (juvenile type), uncontrolled
  

 

Report fifth-digits 0 and 2 even if the patient requires insulin—in which case, you may also report the new code V58.67 (long-term current use of insulin). This can be used as a secondary diagnosis, or as a primary diagnosis when the patient is seen for possible long-term effects rather than diabetic control. (Long-term current use of aspirin was also given a code, V58.66.)

V code changes Gynecologic exam

Per ACOG’s request, V72.3 has been expanded into 2 codes:

V72.31 covers routine gynecologic examination—including a Pap smear, if performed. Thus, do not report V76.2 (special screening for malignant neoplasms, cervix) with V72.31 for the exam. Note, however, that if the patient’s cervix is absent and a vaginal Pap smear is collected at the time of the visit, code V76.47 (routine vaginal Pap smear) is also needed.

V72.32 describes a repeat Pap smear in the following scenario: A patient has an abnormal Pap test and is brought back 3 months later for a follow-up Pap. (The diagnosis for that visit is the abnormal result.) The results come back normal and she is asked to return in a few months. You will use V72.32 for this last encounter.

ACOG clarifies V72.32 may be used more than once at the physician’s discretion, since the usual protocol is to perform more frequent Pap smears until obtaining 3 consecutive negative results. Caveat: Check with your Medicare carrier before using this code for the repeat Pap smears.

Pregnancy tests

With the expansion of V72.4, ICD-9 now has an option for a pregnancy test done prior to a procedure that may harm a fetus, or simply because you suspect pregnancy:

Use V72.40 when you perform a pregnancy test, but have not determined whether the patient is pregnant by the end of the visit (ie, a blood rather than urine test). Note that if the pregnancy test is positive, also report code V22.X, per ICD-9 guidelines. This pregnancy diagnosis can be linked to the CPT pregnancy test code.

Use V72.41 if you confirm she is not pregnant during this visit. (Again, if the test is positive, use code V22.X.)

Hormone replacement therapy

The term “postmenopausal” was moved to a parenthetical note for code V07.4, to denote that this code should be reported anytime a woman is placed on estrogen replacement therapy. ICD-9 also has clarified that it is not appropriate to use V58.69 (long-term [current] use of other high-risk medications) for patients on hormone replacement therapy—instead, select code V07.4.

Screening for osteoporosis

ICD-9 has clarified that code V07.4 should be reported with the code for osteoporosis screening (V82.81), if applicable.

Genetic susceptibility to disease

A new category addresses prophylactic organ removal. Until now, ICD-9 had codes to indicate that an encounter was for organ removal, but not to describe the reason for the removal.

Further, these codes were needed because the “carrier status” codes can be used only when the patient is a disease carrier, able to pass it to offspring—not when she herself is at risk.

Note that before you can use these codes, the patient’s record should show an abnormal gene confirmed by genetic test.

Acquired absence of organ

ICD-9 has clarified that code V45.77 (acquired absence of genital organs), excludes the new FGM status codes (629.20 to 629.23).

Exposure to communicable diseases

The American Academy of Pediatrics requested the addition of exposure codes to viral and other communicable diseases. Most important to Ob/Gyns is exposure to chickenpox (varicella), if the mother was not previously exposed. This new code, V01.71, may be enough to support the medical necessity for laboratory work to test for immunity to chickenpox.

Report code V01.79 for exposure to other viral diseases.

Lack of adequate sleep

New code V69.4 is reported for sleep deprivation, but excludes insomnia.

Q I performed surgical treatment for torsion of the ovary using the following procedures: diagnostic laparoscopy, exploratory laparotomy, detorsion of left tube and ovary, bivalve of left ovary, and left oophoropexy.

Two coding scenarios have been suggested: The first is 58925 (Ovarian cystectomy, unilateral or bilateral) 58825 (Transposition, ovary[s]), and 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing). I hesitate to use these, though, since an ovarian cystectomy was not performed and the tube and ovary were detorsed, not transposed elsewhere.

The second option is 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s]) with modifier -22 (unusual procedural services), plus 49320.Are these appropriate?

A The diagnostic laparoscopy, presumably performed to evaluate the problem, can be coded as 49320—but be aware that you may not receive reimbursement if you planned to do the surgery laparoscopically, then converted to an open procedure.

The exploratory laparotomy is not separately bil lable, since you’ll be billing for open surgical procedures. When this happens, the exploratory becomes integral to the surgical technique.

Next is detorsion of the left ovary: CPT does not have a code for this.

You then bivalved the ovary, which is analogous to performing a wedge resection, code 58920 (Wedge resection or bisection of ovary, unilateral or bilateral).

Finally, for the oophoropexy, you are correct that code 58825 is not applicable. If you had moved the ovary out of harm’s way due to radiation treatment, the procedure is referred to as transposition of the ovary and 58825 is reported. In this case, however, I’m guessing you sutured the ovary in place so it can no longer twist. Like the detorsion, CPT has no code for this.

Your coding options are limited, but I would suggest 58920-22—which covers the bivalving, detorsion, and oophoropexy—plus 49320-59 for the diagnostic laparoscopy. (The “distinct procedure” modifier indicates that the laparoscopy was not integral to the rest of the procedure.)

As far as diagnosis, the code linked to 58920 is 620.5 (Torsion of ovary, ovarian pedicle, or fallopian tube), or 752.0 (Congenital anomalies of ovaries) if you know the problem is congenital. Consider a different diagnosis for the laparoscopy, such as lower quadrant abdominal pain (789.03 or 789.04) or ovarian pain (625.9). Finally, add V64.41 to indicate the conversion from laparoscopy to an open procedure.

Q I performed surgical treatment for torsion of the ovary using the following procedures: diagnostic laparoscopy, exploratory laparotomy, detorsion of left tube and ovary, bivalve of left ovary, and left oophoropexy.

Two coding scenarios have been suggested: The first is 58925 (Ovarian cystectomy, unilateral or bilateral) 58825 (Transposition, ovary[s]), and 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing). I hesitate to use these, though, since an ovarian cystectomy was not performed and the tube and ovary were detorsed, not transposed elsewhere.

The second option is 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s]) with modifier -22 (unusual procedural services), plus 49320.Are these appropriate?

A The diagnostic laparoscopy, presumably performed to evaluate the problem, can be coded as 49320—but be aware that you may not receive reimbursement if you planned to do the surgery laparoscopically, then converted to an open procedure.

The exploratory laparotomy is not separately bil lable, since you’ll be billing for open surgical procedures. When this happens, the exploratory becomes integral to the surgical technique.

Next is detorsion of the left ovary: CPT does not have a code for this.

You then bivalved the ovary, which is analogous to performing a wedge resection, code 58920 (Wedge resection or bisection of ovary, unilateral or bilateral).

Finally, for the oophoropexy, you are correct that code 58825 is not applicable. If you had moved the ovary out of harm’s way due to radiation treatment, the procedure is referred to as transposition of the ovary and 58825 is reported. In this case, however, I’m guessing you sutured the ovary in place so it can no longer twist. Like the detorsion, CPT has no code for this.

Your coding options are limited, but I would suggest 58920-22—which covers the bivalving, detorsion, and oophoropexy—plus 49320-59 for the diagnostic laparoscopy. (The “distinct procedure” modifier indicates that the laparoscopy was not integral to the rest of the procedure.)

As far as diagnosis, the code linked to 58920 is 620.5 (Torsion of ovary, ovarian pedicle, or fallopian tube), or 752.0 (Congenital anomalies of ovaries) if you know the problem is congenital. Consider a different diagnosis for the laparoscopy, such as lower quadrant abdominal pain (789.03 or 789.04) or ovarian pain (625.9). Finally, add V64.41 to indicate the conversion from laparoscopy to an open procedure.

Q I performed surgical treatment for torsion of the ovary using the following procedures: diagnostic laparoscopy, exploratory laparotomy, detorsion of left tube and ovary, bivalve of left ovary, and left oophoropexy.

Two coding scenarios have been suggested: The first is 58925 (Ovarian cystectomy, unilateral or bilateral) 58825 (Transposition, ovary[s]), and 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing). I hesitate to use these, though, since an ovarian cystectomy was not performed and the tube and ovary were detorsed, not transposed elsewhere.

The second option is 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s]) with modifier -22 (unusual procedural services), plus 49320.Are these appropriate?

A The diagnostic laparoscopy, presumably performed to evaluate the problem, can be coded as 49320—but be aware that you may not receive reimbursement if you planned to do the surgery laparoscopically, then converted to an open procedure.

The exploratory laparotomy is not separately bil lable, since you’ll be billing for open surgical procedures. When this happens, the exploratory becomes integral to the surgical technique.

Next is detorsion of the left ovary: CPT does not have a code for this.

You then bivalved the ovary, which is analogous to performing a wedge resection, code 58920 (Wedge resection or bisection of ovary, unilateral or bilateral).

Finally, for the oophoropexy, you are correct that code 58825 is not applicable. If you had moved the ovary out of harm’s way due to radiation treatment, the procedure is referred to as transposition of the ovary and 58825 is reported. In this case, however, I’m guessing you sutured the ovary in place so it can no longer twist. Like the detorsion, CPT has no code for this.

Your coding options are limited, but I would suggest 58920-22—which covers the bivalving, detorsion, and oophoropexy—plus 49320-59 for the diagnostic laparoscopy. (The “distinct procedure” modifier indicates that the laparoscopy was not integral to the rest of the procedure.)

As far as diagnosis, the code linked to 58920 is 620.5 (Torsion of ovary, ovarian pedicle, or fallopian tube), or 752.0 (Congenital anomalies of ovaries) if you know the problem is congenital. Consider a different diagnosis for the laparoscopy, such as lower quadrant abdominal pain (789.03 or 789.04) or ovarian pain (625.9). Finally, add V64.41 to indicate the conversion from laparoscopy to an open procedure.

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?