Reimbursement Advisor

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

<huc>Q</huc> I have a patient with a BRCA mutation that places her at high risk for breast and ovarian cancer. Which diagnosis code should I use?

<huc>A</huc> If you are removing the organ, use V50.42 (prophylactic ovary removal) or V50.49 (other prophylactic organ removal) as the primary diagnosis.

If you simply want to note the mutation as a reason for further evaluation and management (E/M), try V16.3 (family history of breast cancer) or V16.41 (family history of ovarian cancer). You may use these as the primary diagnosis if there is no other reason for the encounter, or as secondary diagnoses.

Current ICD-9 rules do not permit you to code V83.89 (other genetic carrier status) for this scenario. This code is used for patients who carry a disease that can be directly passed on to their offspring, rather than for those at high risk of disease due to genetic predisposition.

ICD-9 has addressed this issue with new codes that go into effect October 1. They will be V84.01 (genetic susceptibility to malignant neoplasm of breast) and V84.02 (genetic susceptibility to malignant neoplasm of ovary). (Look for further discussion of this and other ICD-9 changes in the November issue of OBG Management).

<huc>Q</huc> I have a patient with a BRCA mutation that places her at high risk for breast and ovarian cancer. Which diagnosis code should I use?

<huc>A</huc> If you are removing the organ, use V50.42 (prophylactic ovary removal) or V50.49 (other prophylactic organ removal) as the primary diagnosis.

If you simply want to note the mutation as a reason for further evaluation and management (E/M), try V16.3 (family history of breast cancer) or V16.41 (family history of ovarian cancer). You may use these as the primary diagnosis if there is no other reason for the encounter, or as secondary diagnoses.

Current ICD-9 rules do not permit you to code V83.89 (other genetic carrier status) for this scenario. This code is used for patients who carry a disease that can be directly passed on to their offspring, rather than for those at high risk of disease due to genetic predisposition.

ICD-9 has addressed this issue with new codes that go into effect October 1. They will be V84.01 (genetic susceptibility to malignant neoplasm of breast) and V84.02 (genetic susceptibility to malignant neoplasm of ovary). (Look for further discussion of this and other ICD-9 changes in the November issue of OBG Management).

<huc>Q</huc> I have a patient with a BRCA mutation that places her at high risk for breast and ovarian cancer. Which diagnosis code should I use?

<huc>A</huc> If you are removing the organ, use V50.42 (prophylactic ovary removal) or V50.49 (other prophylactic organ removal) as the primary diagnosis.

If you simply want to note the mutation as a reason for further evaluation and management (E/M), try V16.3 (family history of breast cancer) or V16.41 (family history of ovarian cancer). You may use these as the primary diagnosis if there is no other reason for the encounter, or as secondary diagnoses.

Current ICD-9 rules do not permit you to code V83.89 (other genetic carrier status) for this scenario. This code is used for patients who carry a disease that can be directly passed on to their offspring, rather than for those at high risk of disease due to genetic predisposition.

ICD-9 has addressed this issue with new codes that go into effect October 1. They will be V84.01 (genetic susceptibility to malignant neoplasm of breast) and V84.02 (genetic susceptibility to malignant neoplasm of ovary). (Look for further discussion of this and other ICD-9 changes in the November issue of OBG Management).

Q How do you code a “saddle block” (spinal anesthesia confined to the perineum, buttocks, and inner aspect of the thighs)?

A If you, as the delivering obstetrician, performed the saddle block, add modifier -47 (anesthesia by surgeon) to the delivery code, then add 62311-51 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]; multiple procedure).

If the procedure was performed by an anesthesiologist during vaginal delivery, the code is 01960 (anesthesia for vaginal delivery only).

This is in line with CPT guidelines, but some payers won’t reimburse delivering physicians for the block—so be prepared to appeal, especially if no anesthesiologist was available.

Q How do you code a “saddle block” (spinal anesthesia confined to the perineum, buttocks, and inner aspect of the thighs)?

A If you, as the delivering obstetrician, performed the saddle block, add modifier -47 (anesthesia by surgeon) to the delivery code, then add 62311-51 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]; multiple procedure).

If the procedure was performed by an anesthesiologist during vaginal delivery, the code is 01960 (anesthesia for vaginal delivery only).

This is in line with CPT guidelines, but some payers won’t reimburse delivering physicians for the block—so be prepared to appeal, especially if no anesthesiologist was available.

Q How do you code a “saddle block” (spinal anesthesia confined to the perineum, buttocks, and inner aspect of the thighs)?

A If you, as the delivering obstetrician, performed the saddle block, add modifier -47 (anesthesia by surgeon) to the delivery code, then add 62311-51 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]; multiple procedure).

If the procedure was performed by an anesthesiologist during vaginal delivery, the code is 01960 (anesthesia for vaginal delivery only).

This is in line with CPT guidelines, but some payers won’t reimburse delivering physicians for the block—so be prepared to appeal, especially if no anesthesiologist was available.

Q I performed laparoscopic evaluation of a patient with pelvic pain who came to the emergency room (ER). The woman was found to have both a hemorrhagic ovarian cyst, which was cauterized, and appendicitis, for which an appendectomy was performed. What are the rules for billing these procedures together?

A Were you called for a consultation in the ER? If so, bill an outpatient consultation code with modifier -57 (decision to do surgery), as this was the visit at which surgical intervention was deemed necessary. (I assume the procedure was performed either the day of or the day after the decision.)

If no consultation was requested, use an outpatient code for the service, again with modifier -57. If the ER physician is billing for an ER service, you should not do so.

As for the surgery itself: For the cyst cautery, use 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method); for the appendectomy, use 44970 (laparoscopy, surgical, appendectomy) with modifier -51 (multiple procedure). You can bill these together, as a different diagnosis supports each procedure and the appendectomy was not incidental.

If you assisted on the appendectomy, still bill codes 58662 and 44970, but add modifier -80 (assistant surgeon) to the latter code.

Q I performed laparoscopic evaluation of a patient with pelvic pain who came to the emergency room (ER). The woman was found to have both a hemorrhagic ovarian cyst, which was cauterized, and appendicitis, for which an appendectomy was performed. What are the rules for billing these procedures together?

A Were you called for a consultation in the ER? If so, bill an outpatient consultation code with modifier -57 (decision to do surgery), as this was the visit at which surgical intervention was deemed necessary. (I assume the procedure was performed either the day of or the day after the decision.)

If no consultation was requested, use an outpatient code for the service, again with modifier -57. If the ER physician is billing for an ER service, you should not do so.

As for the surgery itself: For the cyst cautery, use 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method); for the appendectomy, use 44970 (laparoscopy, surgical, appendectomy) with modifier -51 (multiple procedure). You can bill these together, as a different diagnosis supports each procedure and the appendectomy was not incidental.

If you assisted on the appendectomy, still bill codes 58662 and 44970, but add modifier -80 (assistant surgeon) to the latter code.

Q I performed laparoscopic evaluation of a patient with pelvic pain who came to the emergency room (ER). The woman was found to have both a hemorrhagic ovarian cyst, which was cauterized, and appendicitis, for which an appendectomy was performed. What are the rules for billing these procedures together?

A Were you called for a consultation in the ER? If so, bill an outpatient consultation code with modifier -57 (decision to do surgery), as this was the visit at which surgical intervention was deemed necessary. (I assume the procedure was performed either the day of or the day after the decision.)

If no consultation was requested, use an outpatient code for the service, again with modifier -57. If the ER physician is billing for an ER service, you should not do so.

As for the surgery itself: For the cyst cautery, use 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method); for the appendectomy, use 44970 (laparoscopy, surgical, appendectomy) with modifier -51 (multiple procedure). You can bill these together, as a different diagnosis supports each procedure and the appendectomy was not incidental.

If you assisted on the appendectomy, still bill codes 58662 and 44970, but add modifier -80 (assistant surgeon) to the latter code.

Q We treated an ectopic pregnancy with an injection of potassium chloride transvaginally. How is this coded?

A First, was ultrasound guidance of the needle used—and documented? If so, you can report 76942 (ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging, supervision, and interpretation).

CPT does not have a code for the injection itself, and I do not advise the unlisted injection procedure code—that implies an injection in the skin or another easily accessibly location. I recommend 59899 (unlisted procedure, maternity care and delivery). You will need to submit documentation with this claim.

Q We treated an ectopic pregnancy with an injection of potassium chloride transvaginally. How is this coded?

A First, was ultrasound guidance of the needle used—and documented? If so, you can report 76942 (ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging, supervision, and interpretation).

CPT does not have a code for the injection itself, and I do not advise the unlisted injection procedure code—that implies an injection in the skin or another easily accessibly location. I recommend 59899 (unlisted procedure, maternity care and delivery). You will need to submit documentation with this claim.

Q We treated an ectopic pregnancy with an injection of potassium chloride transvaginally. How is this coded?

A First, was ultrasound guidance of the needle used—and documented? If so, you can report 76942 (ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging, supervision, and interpretation).

CPT does not have a code for the injection itself, and I do not advise the unlisted injection procedure code—that implies an injection in the skin or another easily accessibly location. I recommend 59899 (unlisted procedure, maternity care and delivery). You will need to submit documentation with this claim.

Q We performed a circumcision in the office. Code 54150 is listed as “Circumcision with a clamp on a newborn,” while 54152 is simply “Circumcision with a clamp.” What is the definition of newborn?

A “Newborn” refers to a liveborn infant during the first 25 days, 23 hours, and 59 minutes of life (from the 1972 American College of Obstetricians and Gynecologists book Obstetric-Gynecologic Terminology, edited by Edward C. Hughes, MD). CPT uses this same definition.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We performed a circumcision in the office. Code 54150 is listed as “Circumcision with a clamp on a newborn,” while 54152 is simply “Circumcision with a clamp.” What is the definition of newborn?

A “Newborn” refers to a liveborn infant during the first 25 days, 23 hours, and 59 minutes of life (from the 1972 American College of Obstetricians and Gynecologists book Obstetric-Gynecologic Terminology, edited by Edward C. Hughes, MD). CPT uses this same definition.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We performed a circumcision in the office. Code 54150 is listed as “Circumcision with a clamp on a newborn,” while 54152 is simply “Circumcision with a clamp.” What is the definition of newborn?

A “Newborn” refers to a liveborn infant during the first 25 days, 23 hours, and 59 minutes of life (from the 1972 American College of Obstetricians and Gynecologists book Obstetric-Gynecologic Terminology, edited by Edward C. Hughes, MD). CPT uses this same definition.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I billed a nonstress test (NST) that was rejected. The note in the chart says the test was nonreactive. What should I do? Should we not have billed the NST at all, or can I just submit a diagnosis of no fetal movement?

A A nonreactive fetal NST is the finding of the exam—not the reason it was conducted. To justify performing the NST, you need to consider why it was ordered in the first place. Since this exam is done to measure fetal well-being, there are several possibilities.

To name just a few:

• complaints of decreased fetal movement (655.73)
  
• fetal size that is small or large for dates (656.53 or 656.63)
  
• previous intrauterine fetal demise (V23.49)
  
• abnormal fetal heart rate (659.73)
  
• maternal abdominal trauma (659.83, along with a diagnosis indicating the injury)
  

Whatever the reason for the test, make sure it is documented; if it is not and the records are audited, returning money to the payer would be your best-case scenario. The worst-case scenario? Accusations of fraud for billing a service not documented (meaning, to the payer, that it never happened).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I billed a nonstress test (NST) that was rejected. The note in the chart says the test was nonreactive. What should I do? Should we not have billed the NST at all, or can I just submit a diagnosis of no fetal movement?

A A nonreactive fetal NST is the finding of the exam—not the reason it was conducted. To justify performing the NST, you need to consider why it was ordered in the first place. Since this exam is done to measure fetal well-being, there are several possibilities.

To name just a few:

• complaints of decreased fetal movement (655.73)
  
• fetal size that is small or large for dates (656.53 or 656.63)
  
• previous intrauterine fetal demise (V23.49)
  
• abnormal fetal heart rate (659.73)
  
• maternal abdominal trauma (659.83, along with a diagnosis indicating the injury)
  

Whatever the reason for the test, make sure it is documented; if it is not and the records are audited, returning money to the payer would be your best-case scenario. The worst-case scenario? Accusations of fraud for billing a service not documented (meaning, to the payer, that it never happened).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I billed a nonstress test (NST) that was rejected. The note in the chart says the test was nonreactive. What should I do? Should we not have billed the NST at all, or can I just submit a diagnosis of no fetal movement?

A A nonreactive fetal NST is the finding of the exam—not the reason it was conducted. To justify performing the NST, you need to consider why it was ordered in the first place. Since this exam is done to measure fetal well-being, there are several possibilities.

To name just a few:

• complaints of decreased fetal movement (655.73)
  
• fetal size that is small or large for dates (656.53 or 656.63)
  
• previous intrauterine fetal demise (V23.49)
  
• abnormal fetal heart rate (659.73)
  
• maternal abdominal trauma (659.83, along with a diagnosis indicating the injury)
  

Whatever the reason for the test, make sure it is documented; if it is not and the records are audited, returning money to the payer would be your best-case scenario. The worst-case scenario? Accusations of fraud for billing a service not documented (meaning, to the payer, that it never happened).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We performed a postcoital examination on a patient. We have always used 89300 (semen analysis; presence and/or motility of sperm including Huhner test [post coital]), but now an insurance company has denied the claim. Any suggestions?

A First you need to determine the rationale for the denial. One of the most common reasons for denial of a service is an improper diagnosis code. Inquire if the payer objected to something specific about the code you used. For instance, some insurance companies will accept a diagnosis of infertility testing (V26.29, other investigation or testing; or V26.21, fertility testing) as the reason for the postcoital test, while others require an infertility diagnosis—either female or male.

Another issue may be that the patient does not have coverage for infertility services, including testing.

If neither of these is the problem, and the payer won’t simply tell you how to bill for the exam, you might try the Health Care Financing Administration Common Procedure Coding System (HCPCS) code for this service, Q0115 (post-coital direct, qualitative examinations of vaginal or cervical mucous).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We performed a postcoital examination on a patient. We have always used 89300 (semen analysis; presence and/or motility of sperm including Huhner test [post coital]), but now an insurance company has denied the claim. Any suggestions?

A First you need to determine the rationale for the denial. One of the most common reasons for denial of a service is an improper diagnosis code. Inquire if the payer objected to something specific about the code you used. For instance, some insurance companies will accept a diagnosis of infertility testing (V26.29, other investigation or testing; or V26.21, fertility testing) as the reason for the postcoital test, while others require an infertility diagnosis—either female or male.

Another issue may be that the patient does not have coverage for infertility services, including testing.

If neither of these is the problem, and the payer won’t simply tell you how to bill for the exam, you might try the Health Care Financing Administration Common Procedure Coding System (HCPCS) code for this service, Q0115 (post-coital direct, qualitative examinations of vaginal or cervical mucous).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We performed a postcoital examination on a patient. We have always used 89300 (semen analysis; presence and/or motility of sperm including Huhner test [post coital]), but now an insurance company has denied the claim. Any suggestions?

A First you need to determine the rationale for the denial. One of the most common reasons for denial of a service is an improper diagnosis code. Inquire if the payer objected to something specific about the code you used. For instance, some insurance companies will accept a diagnosis of infertility testing (V26.29, other investigation or testing; or V26.21, fertility testing) as the reason for the postcoital test, while others require an infertility diagnosis—either female or male.

Another issue may be that the patient does not have coverage for infertility services, including testing.

If neither of these is the problem, and the payer won’t simply tell you how to bill for the exam, you might try the Health Care Financing Administration Common Procedure Coding System (HCPCS) code for this service, Q0115 (post-coital direct, qualitative examinations of vaginal or cervical mucous).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.