Reimbursement Advisor

Q I have searched, but cannot find a code for what the physician is calling a “friable cervix.” Can you help?

A The friable cervix is one that is prone to bleeding. The underlying cause is usually chlamydia infection, cervical erosion, or, sometimes, cervical cancer.

If the physician is trying to rule out infection or if all tests are negative, use the code for the patient’s symptom. Possible choices include cervical inflammation (616.0), cervical erosion (622.0), pain with intercourse (625.0), and other abnormal bleeding from the female genital tract (626.8). Once the reason for the friable cervix is determined, that becomes the diagnosis.

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 have searched, but cannot find a code for what the physician is calling a “friable cervix.” Can you help?

A The friable cervix is one that is prone to bleeding. The underlying cause is usually chlamydia infection, cervical erosion, or, sometimes, cervical cancer.

If the physician is trying to rule out infection or if all tests are negative, use the code for the patient’s symptom. Possible choices include cervical inflammation (616.0), cervical erosion (622.0), pain with intercourse (625.0), and other abnormal bleeding from the female genital tract (626.8). Once the reason for the friable cervix is determined, that becomes the diagnosis.

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 have searched, but cannot find a code for what the physician is calling a “friable cervix.” Can you help?

A The friable cervix is one that is prone to bleeding. The underlying cause is usually chlamydia infection, cervical erosion, or, sometimes, cervical cancer.

If the physician is trying to rule out infection or if all tests are negative, use the code for the patient’s symptom. Possible choices include cervical inflammation (616.0), cervical erosion (622.0), pain with intercourse (625.0), and other abnormal bleeding from the female genital tract (626.8). Once the reason for the friable cervix is determined, that becomes the diagnosis.

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 Some pregnant patients (trauma cases, etc) go through our hospital emergency room (ER), but most go to our labor and delivery triage center, which is staffed by residents 24 hours a day, with an in-house attending always available. Some universities I know use ER codes for triage-center billing, because they feel it meets the requirements of an ER. Is this acceptable?

A No. Both Medicare and CPT guidelines state that to use the ER services codes, you must provide the service in the hospital’s designated emergency room or department. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. Within this definition, there is the tacit understanding that such care must be provided to all, without discrimination as to gender or age. You have stated that your hospital has a designated ER; thus, the emergency services codes (99281-99285) are appropriate only when care is provided in that setting.

If physicians in the labor and delivery center are seeing pregnant patients for triage, your coding choices are:

• observation care admission (99218-99220),
  
• observation care discharge (99217),
  
• same-day observation admission and discharge (99234-99236),
  
• outpatient care (99201-99215), or
  
• outpatient consultations (99241-99245).
  

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 Some pregnant patients (trauma cases, etc) go through our hospital emergency room (ER), but most go to our labor and delivery triage center, which is staffed by residents 24 hours a day, with an in-house attending always available. Some universities I know use ER codes for triage-center billing, because they feel it meets the requirements of an ER. Is this acceptable?

A No. Both Medicare and CPT guidelines state that to use the ER services codes, you must provide the service in the hospital’s designated emergency room or department. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. Within this definition, there is the tacit understanding that such care must be provided to all, without discrimination as to gender or age. You have stated that your hospital has a designated ER; thus, the emergency services codes (99281-99285) are appropriate only when care is provided in that setting.

If physicians in the labor and delivery center are seeing pregnant patients for triage, your coding choices are:

• observation care admission (99218-99220),
  
• observation care discharge (99217),
  
• same-day observation admission and discharge (99234-99236),
  
• outpatient care (99201-99215), or
  
• outpatient consultations (99241-99245).
  

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 Some pregnant patients (trauma cases, etc) go through our hospital emergency room (ER), but most go to our labor and delivery triage center, which is staffed by residents 24 hours a day, with an in-house attending always available. Some universities I know use ER codes for triage-center billing, because they feel it meets the requirements of an ER. Is this acceptable?

A No. Both Medicare and CPT guidelines state that to use the ER services codes, you must provide the service in the hospital’s designated emergency room or department. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. Within this definition, there is the tacit understanding that such care must be provided to all, without discrimination as to gender or age. You have stated that your hospital has a designated ER; thus, the emergency services codes (99281-99285) are appropriate only when care is provided in that setting.

If physicians in the labor and delivery center are seeing pregnant patients for triage, your coding choices are:

• observation care admission (99218-99220),
  
• observation care discharge (99217),
  
• same-day observation admission and discharge (99234-99236),
  
• outpatient care (99201-99215), or
  
• outpatient consultations (99241-99245).
  

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 One of my doctors performed a postcoital analysis of a patient’s mucous due to infertility issues. The physician called it a Sims-Huhner test. How should I code for this service?

A The postcoital test—also known as the Sims-Huhner, or Huhner, test—analyzes the cervical canal after sexual intercourse to determine whether sperm are present and moving. The cervical mucus also may be evaluated to determine its elasticity and drying pattern.

The test is performed 1 to 2 days before ovulation is expected, when the cervical mucus is thin, elastic, and easily penetrable by sperm. Two to 4 hours after the couple has sexual intercourse (without lubricants), a clinician collects the specimen and analyzes it under a microscope.

As it happens, there is a non-CPT code for this procedure: code Q0115, (postcoital direct, qualitative examinations of vaginal or cervical mucous). It is part of the HIPAA-specified code set, and as such may be used to bill for the procedure. Note this is considered a physician-performed microscopy (PPM) procedure, which requires a Clinical Laboratories Improvement Amendments PPM certificate.

A good second choice is the CPT code 89300 (presence and/or motility of sperm including Huhner test [postcoital]), which includes semen analysis. Some infertility physicians I have spoken with recommend using 89300 for the Huhner test even when the semen analysis is not performed. In this scenario, you might consider adding the modifier -52 (reduced services) to be truly “coding accurate.”

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 One of my doctors performed a postcoital analysis of a patient’s mucous due to infertility issues. The physician called it a Sims-Huhner test. How should I code for this service?

A The postcoital test—also known as the Sims-Huhner, or Huhner, test—analyzes the cervical canal after sexual intercourse to determine whether sperm are present and moving. The cervical mucus also may be evaluated to determine its elasticity and drying pattern.

The test is performed 1 to 2 days before ovulation is expected, when the cervical mucus is thin, elastic, and easily penetrable by sperm. Two to 4 hours after the couple has sexual intercourse (without lubricants), a clinician collects the specimen and analyzes it under a microscope.

As it happens, there is a non-CPT code for this procedure: code Q0115, (postcoital direct, qualitative examinations of vaginal or cervical mucous). It is part of the HIPAA-specified code set, and as such may be used to bill for the procedure. Note this is considered a physician-performed microscopy (PPM) procedure, which requires a Clinical Laboratories Improvement Amendments PPM certificate.

A good second choice is the CPT code 89300 (presence and/or motility of sperm including Huhner test [postcoital]), which includes semen analysis. Some infertility physicians I have spoken with recommend using 89300 for the Huhner test even when the semen analysis is not performed. In this scenario, you might consider adding the modifier -52 (reduced services) to be truly “coding accurate.”

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 One of my doctors performed a postcoital analysis of a patient’s mucous due to infertility issues. The physician called it a Sims-Huhner test. How should I code for this service?

A The postcoital test—also known as the Sims-Huhner, or Huhner, test—analyzes the cervical canal after sexual intercourse to determine whether sperm are present and moving. The cervical mucus also may be evaluated to determine its elasticity and drying pattern.

The test is performed 1 to 2 days before ovulation is expected, when the cervical mucus is thin, elastic, and easily penetrable by sperm. Two to 4 hours after the couple has sexual intercourse (without lubricants), a clinician collects the specimen and analyzes it under a microscope.

As it happens, there is a non-CPT code for this procedure: code Q0115, (postcoital direct, qualitative examinations of vaginal or cervical mucous). It is part of the HIPAA-specified code set, and as such may be used to bill for the procedure. Note this is considered a physician-performed microscopy (PPM) procedure, which requires a Clinical Laboratories Improvement Amendments PPM certificate.

A good second choice is the CPT code 89300 (presence and/or motility of sperm including Huhner test [postcoital]), which includes semen analysis. Some infertility physicians I have spoken with recommend using 89300 for the Huhner test even when the semen analysis is not performed. In this scenario, you might consider adding the modifier -52 (reduced services) to be truly “coding accurate.”

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.

Maternal-fetal medicine physicians, infertility specialists, gynecologic surgeons, and the folks behind HIPAA top the list of professionals cheering the updates to Current Procedural Terminology (CPT) 2004.

Among the revisions making the biggest splash for Ob/Gyns in this year’s manual:

• the addition of new codes for fetal surgical procedures—interventions that previously could be reported only with an unlisted procedure code;
  
• a new code for laparoscopic colpopexy;
  
• a revamp of the infertility lab procedure codes to incorporate advanced procedures utilizing newer technology; and
  
• the addition of the new Category II codes—necessary to bring CPT in line with HIPAA requirements, thus allowing it to remain the coding system of choice for physician services.
  

Of course, a number of other changes also may affect Ob/Gyn practice. Thus, a “best of the rest” roundup is also included.

BEST OF THE BEST

Fetal intrauterine procedures

By adding 5 new codes for fetal intrauterine surgical procedures—including an “unlisted procedure” code—to the “maternity care and delivery” section, CPT brings out of the investigational arena some techniques that can be used to treat the fetus in utero or aid in the evaluation of the fetal condition.

Note that since all of the codes include ultrasound guidance, you will not need a second code from the radiology section.

• 59070 Transabdominal amnioinfusion, including ultrasound guidance

The procedure itself involves performing an amniocentesis, then guiding the needle between the fetal extremities. Sterile saline is instilled under continuous ultrasound until adequate visualization of the fetal anatomy is possible. After the needle is removed, a detailed ultrasound of the fetus is performed. This can be coded separately by reporting 76811 (as well as 76812 if there is more than 1 fetus). Note, however, that this code would not be reported if the sterile saline is introduced via the cervix, as this is not an “invasive” procedure; instead, use the unlisted code 59899.

• 59072 Fetal umbilical cord occlusion, including ultrasound guidance

This is performed when 1 fetus in a set of monochorionic twins has a severe fetal anomaly. In the procedure, blood flow from the umbilical cord to the affected fetus is occluded, using either laser, suture, or bipolar coagulation. Ultrasound, including color Doppler, is used to confirm complete absence of flow through the occluded cord. Because the purpose of the Doppler is to check the success of the occlusion, it is not coded separately.

• 59074 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance

For these procedures, the surgeon aspirates fluid from fetal body cavities or organs to help evaluate or treat congenital abnormalities. Fetal bladder aspiration is one example; in this procedure, the physician directs the needle into the fetal bladder and aspirates fetal urine. The patient is monitored after the needle is removed and an ultrasound is performed again in about 1 hour to check for bladder refilling. Since the postprocedure ultrasound is diagnostic in nature, it can be billed for separately, but some payers may conclude that it is part of the procedure.

• 59076 Fetal shunt placement, including ultrasound guidance

This procedure involves the percutaneous placement of a double-pigtailed catheter into the area that requires drainage (the fetal bladder or the thorax, if the problem is pleural effusion). Once the catheter is in place, the other end is inserted into the amniotic cavity, so the fluid can travel into this space. The patient and fetus are monitored for an hour or longer and a repeat scan is performed to evaluate drainage and reaccumulation of amniotic fluid. In this case, the repeat scan will probably be considered part of the procedure, as it is done to check the intervention’s success.

• 59897 Unlisted fetal invasive procedure, including ultrasound guidance

Laparoscopic colpopexy

• 57425 Laparoscopy, surgical, colpopexy (suspension of vaginal apex)

With many surgeons now performing colpopexy laparoscopically, rather than abdominally, this new code (added to the “female genital system” section of “Surgical procedures”) is sure to solve some coding headaches.

For this procedure, which is normally done on patients with uterovaginal prolapse or prolapse of the vaginal vault following a hysterectomy, a Halban or McCall’s culdoplasty is performed to obliterate the cul-desac,and a graft is secured to the pubocervical and rectovaginal fascia. The physician may also do presacral dissection, so that the graft can be secured to the sacrum’s anterior longitudinal ligament. Any adhesions are lysed to gain access to the vaginal apex—this lysis is not normally coded separately.

Also changed in this section:

• 58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography or hysterosalpingography

 

Code 58340 has been revised to reflect more current terminology. The term “hysterosonography” has been changed to “saline infusion sonohysterography.” A similar change applies to the radiological supervision code 76831 [saline infusion sonohysterography, including color flow Doppler, when performed]. This change does not alter the use of the codes in any way.

Reproductive medicine procedures

This new section of laboratory codes accommodates the technologic advancements and changing practice in reproductive medicine.

The procedures are grouped into 3 categories, by type of procedure:

• Oocyte/embryo culture and fertilization techniques;
  
• Oocyte/embryo biopsy techniques; and
  
• Freezing, thawing, and storage techniques.
  

These are nonphysician procedures performed in highly specialized clinical laboratories; any physician services provided at the same time may be reported in addition. In creating this new section, codes 89252 and 89256 were deleted and renumbered to 89280/89281 and 89352, respectively.

In addition, there are 2 new Category III codes for cryopreservation of tissue and oocytes. If the procedure performed matches one of these new Category III codes, it must be reported rather than an unlisted service code. The new and revised codes can be found in the Table.

TABLE

Reproductive medicine procedures

OOCYTE/EMBRYO CULTURE AND FERTILIZATION TECHNIQUES
• 89250	Culture of oocyte(s)/embryo(s), less than 4 days;*
• 89251	with coculture of oocyte(s)/embryos†
• 89268	Insemination of oocytes
• 89272	Extended culture of oocyte(s)/embryo(s), 4-7 days‡
• 89280	Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
• 89281	greater than 10 oocytes
OOCYTE/EMBRYO BIOPSY TECHNIQUES
• 89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); less than or equal to 5 embryos
• 89291	greater than 5 embryos
FREEZING, THAWING, AND STORAGE TECHNIQUES
• 89258	Cryopreservation; embryo(s)
• 89335	Cryopreservation, reproductive tissue, testicular
• 89342	Storage (per year); embryo(s)
• 89343	sperm/semen
• 89344	reproductive tissue, testicular/ovarian
• 89346	oocyte
• 89352	Thawing of cryopreserved; embryo(s)
• 89353	sperm/semen, each aliquot
• 89354	reproductive tissue, testicular/ovarian
• 89356	oocytes, each aliquot
CATEGORY III CODES
• 0058T	Cryopreservation of reproductive tissue, ovarian
• 0059T	Cryopreservation of oocyte(s)
* You can now use code 89250 to report the culture of immature oocytes. Fertilization and insemination are no longer considered part of this code, and thus are reported separately.
† Code 89251 represents the additional work of the microfertilization of more than 10 oocytes.
‡ Use code 89272 to report separate techniques for additional cultures over a 4- to 7-day period and in addition to code 89250.

Staying hip to HIPAA: Category II codes

This new section, which adds supplemental tracking codes for performance measurements, was created in an effort to comply with HIPAA regulation requirements for the code set. These codes will not affect reimbursement, but are meant to decrease the need for record abstraction and chart review. Use of these codes, it is hoped, will facilitate data collection about quality of care. Coders should be aware of the following:

• The use of these codes is optional; they may not be substituted for the regular Category I CPT codes.
  
• The codes describe components typically included in an evaluation and management service, as well as test results that are part of the laboratory test/procedure.
  
• The codes are assigned no relative value units.
  
• New codes for this section will be released semiannually. Updates can be found on the AMA/CPT Web site (www.ama-assn.org/ama/pub/category/3885.html).
  

The codes will be published in the CPT each year.

The Category II codes effective January 1, 2004, are:

• 0001FBlood pressure, measured
  
• 0002FTobacco use, smoking, assessed
  
• 0003FTobacco use, nonsmoking, assessed
  
• 0004FTobacco use cessation intervention, counseling
  
• 0005FTobacco use cessation intervention, pharmacologic therapy
  
• 0006FStatin therapy, prescribed
  
• 0007FBeta-blocker therapy, prescribed
  
• 0008FAngiotensin-converting enzyme inhibitor therapy, prescribed
  
• 0009FAnginal symptoms and level of activity, assessed
  
• 0010FAnginal symptoms and level of activity, assessed using a standardized instrument (eg, Canadian Cardiovascular Society Classification-CCSC-System, Seattle Angina Questionnaire-SAQ)
  
• 0011FOral antiplatelet therapy, prescribed (eg, aspirin, clopidogrel/Plavix, or combination of aspirin and dipyridamole/Aggrenox)
  

BEST OF THE REST

Surgical procedures Urinary system.

• 53500Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring)

This new code is for the treatment of obstructive voiding caused by periurethral scarring, which can occur following a urethral suspension procedure, such as a bladder neck suspension. The procedure associated with this new code usually involves the dissection, lysis, and removal of the periurethral scar tissue, as well as mobilization of the urethra away from the surrounding tissues. This code also includes cystourethroscopy (52000), which is sometimes performed to check the urethra after the procedure is done.

In addition, CPT indicates that if urethrolysis is performed via a retropubic rather than vaginal approach, unlisted code 53899 should be reported instead of 53500.

Medicine code changes

 

Miscellaneous services. Code 99025 [initial (new patient) visit when starred (*) surgical procedure constitutes major service at that visit] was deleted, due to the elimination of all starred procedures in CPT 2004. Thus, billing for an evaluation and management service on the same date as an office (minor) procedure will depend on the documentation. The evaluation and management service must be separate and significant from the office service. For global periods assigned to individual CPT procedures codes, coders should either reference the Medicare global periods or consult with their individual private payers, who may assign global days based on community standards.

A new instruction for 99080 [special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form] indicates that this code should not be reported with the Work Related or Medical Disability Evaluation codes 99455 and 99456, since these codes include completion of Workmen’s Compensation forms.

Additional changes to this section include:

• 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure
  
• 99050 Services requested after posted office hours in addition to basic service
  

Maternal-fetal medicine physicians, infertility specialists, gynecologic surgeons, and the folks behind HIPAA top the list of professionals cheering the updates to Current Procedural Terminology (CPT) 2004.

Among the revisions making the biggest splash for Ob/Gyns in this year’s manual:

• the addition of new codes for fetal surgical procedures—interventions that previously could be reported only with an unlisted procedure code;
  
• a new code for laparoscopic colpopexy;
  
• a revamp of the infertility lab procedure codes to incorporate advanced procedures utilizing newer technology; and
  
• the addition of the new Category II codes—necessary to bring CPT in line with HIPAA requirements, thus allowing it to remain the coding system of choice for physician services.
  

Of course, a number of other changes also may affect Ob/Gyn practice. Thus, a “best of the rest” roundup is also included.

BEST OF THE BEST

Fetal intrauterine procedures

By adding 5 new codes for fetal intrauterine surgical procedures—including an “unlisted procedure” code—to the “maternity care and delivery” section, CPT brings out of the investigational arena some techniques that can be used to treat the fetus in utero or aid in the evaluation of the fetal condition.

Note that since all of the codes include ultrasound guidance, you will not need a second code from the radiology section.

• 59070 Transabdominal amnioinfusion, including ultrasound guidance

The procedure itself involves performing an amniocentesis, then guiding the needle between the fetal extremities. Sterile saline is instilled under continuous ultrasound until adequate visualization of the fetal anatomy is possible. After the needle is removed, a detailed ultrasound of the fetus is performed. This can be coded separately by reporting 76811 (as well as 76812 if there is more than 1 fetus). Note, however, that this code would not be reported if the sterile saline is introduced via the cervix, as this is not an “invasive” procedure; instead, use the unlisted code 59899.

• 59072 Fetal umbilical cord occlusion, including ultrasound guidance

This is performed when 1 fetus in a set of monochorionic twins has a severe fetal anomaly. In the procedure, blood flow from the umbilical cord to the affected fetus is occluded, using either laser, suture, or bipolar coagulation. Ultrasound, including color Doppler, is used to confirm complete absence of flow through the occluded cord. Because the purpose of the Doppler is to check the success of the occlusion, it is not coded separately.

• 59074 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance

For these procedures, the surgeon aspirates fluid from fetal body cavities or organs to help evaluate or treat congenital abnormalities. Fetal bladder aspiration is one example; in this procedure, the physician directs the needle into the fetal bladder and aspirates fetal urine. The patient is monitored after the needle is removed and an ultrasound is performed again in about 1 hour to check for bladder refilling. Since the postprocedure ultrasound is diagnostic in nature, it can be billed for separately, but some payers may conclude that it is part of the procedure.

• 59076 Fetal shunt placement, including ultrasound guidance

This procedure involves the percutaneous placement of a double-pigtailed catheter into the area that requires drainage (the fetal bladder or the thorax, if the problem is pleural effusion). Once the catheter is in place, the other end is inserted into the amniotic cavity, so the fluid can travel into this space. The patient and fetus are monitored for an hour or longer and a repeat scan is performed to evaluate drainage and reaccumulation of amniotic fluid. In this case, the repeat scan will probably be considered part of the procedure, as it is done to check the intervention’s success.

• 59897 Unlisted fetal invasive procedure, including ultrasound guidance

Laparoscopic colpopexy

• 57425 Laparoscopy, surgical, colpopexy (suspension of vaginal apex)

With many surgeons now performing colpopexy laparoscopically, rather than abdominally, this new code (added to the “female genital system” section of “Surgical procedures”) is sure to solve some coding headaches.

For this procedure, which is normally done on patients with uterovaginal prolapse or prolapse of the vaginal vault following a hysterectomy, a Halban or McCall’s culdoplasty is performed to obliterate the cul-desac,and a graft is secured to the pubocervical and rectovaginal fascia. The physician may also do presacral dissection, so that the graft can be secured to the sacrum’s anterior longitudinal ligament. Any adhesions are lysed to gain access to the vaginal apex—this lysis is not normally coded separately.

Also changed in this section:

• 58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography or hysterosalpingography

 

Code 58340 has been revised to reflect more current terminology. The term “hysterosonography” has been changed to “saline infusion sonohysterography.” A similar change applies to the radiological supervision code 76831 [saline infusion sonohysterography, including color flow Doppler, when performed]. This change does not alter the use of the codes in any way.

Reproductive medicine procedures

This new section of laboratory codes accommodates the technologic advancements and changing practice in reproductive medicine.

The procedures are grouped into 3 categories, by type of procedure:

• Oocyte/embryo culture and fertilization techniques;
  
• Oocyte/embryo biopsy techniques; and
  
• Freezing, thawing, and storage techniques.
  

These are nonphysician procedures performed in highly specialized clinical laboratories; any physician services provided at the same time may be reported in addition. In creating this new section, codes 89252 and 89256 were deleted and renumbered to 89280/89281 and 89352, respectively.

In addition, there are 2 new Category III codes for cryopreservation of tissue and oocytes. If the procedure performed matches one of these new Category III codes, it must be reported rather than an unlisted service code. The new and revised codes can be found in the Table.

TABLE

Reproductive medicine procedures

OOCYTE/EMBRYO CULTURE AND FERTILIZATION TECHNIQUES
• 89250	Culture of oocyte(s)/embryo(s), less than 4 days;*
• 89251	with coculture of oocyte(s)/embryos†
• 89268	Insemination of oocytes
• 89272	Extended culture of oocyte(s)/embryo(s), 4-7 days‡
• 89280	Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
• 89281	greater than 10 oocytes
OOCYTE/EMBRYO BIOPSY TECHNIQUES
• 89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); less than or equal to 5 embryos
• 89291	greater than 5 embryos
FREEZING, THAWING, AND STORAGE TECHNIQUES
• 89258	Cryopreservation; embryo(s)
• 89335	Cryopreservation, reproductive tissue, testicular
• 89342	Storage (per year); embryo(s)
• 89343	sperm/semen
• 89344	reproductive tissue, testicular/ovarian
• 89346	oocyte
• 89352	Thawing of cryopreserved; embryo(s)
• 89353	sperm/semen, each aliquot
• 89354	reproductive tissue, testicular/ovarian
• 89356	oocytes, each aliquot
CATEGORY III CODES
• 0058T	Cryopreservation of reproductive tissue, ovarian
• 0059T	Cryopreservation of oocyte(s)
* You can now use code 89250 to report the culture of immature oocytes. Fertilization and insemination are no longer considered part of this code, and thus are reported separately.
† Code 89251 represents the additional work of the microfertilization of more than 10 oocytes.
‡ Use code 89272 to report separate techniques for additional cultures over a 4- to 7-day period and in addition to code 89250.

Staying hip to HIPAA: Category II codes

This new section, which adds supplemental tracking codes for performance measurements, was created in an effort to comply with HIPAA regulation requirements for the code set. These codes will not affect reimbursement, but are meant to decrease the need for record abstraction and chart review. Use of these codes, it is hoped, will facilitate data collection about quality of care. Coders should be aware of the following:

• The use of these codes is optional; they may not be substituted for the regular Category I CPT codes.
  
• The codes describe components typically included in an evaluation and management service, as well as test results that are part of the laboratory test/procedure.
  
• The codes are assigned no relative value units.
  
• New codes for this section will be released semiannually. Updates can be found on the AMA/CPT Web site (www.ama-assn.org/ama/pub/category/3885.html).
  

The codes will be published in the CPT each year.

The Category II codes effective January 1, 2004, are:

• 0001FBlood pressure, measured
  
• 0002FTobacco use, smoking, assessed
  
• 0003FTobacco use, nonsmoking, assessed
  
• 0004FTobacco use cessation intervention, counseling
  
• 0005FTobacco use cessation intervention, pharmacologic therapy
  
• 0006FStatin therapy, prescribed
  
• 0007FBeta-blocker therapy, prescribed
  
• 0008FAngiotensin-converting enzyme inhibitor therapy, prescribed
  
• 0009FAnginal symptoms and level of activity, assessed
  
• 0010FAnginal symptoms and level of activity, assessed using a standardized instrument (eg, Canadian Cardiovascular Society Classification-CCSC-System, Seattle Angina Questionnaire-SAQ)
  
• 0011FOral antiplatelet therapy, prescribed (eg, aspirin, clopidogrel/Plavix, or combination of aspirin and dipyridamole/Aggrenox)
  

BEST OF THE REST

Surgical procedures Urinary system.

• 53500Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring)

This new code is for the treatment of obstructive voiding caused by periurethral scarring, which can occur following a urethral suspension procedure, such as a bladder neck suspension. The procedure associated with this new code usually involves the dissection, lysis, and removal of the periurethral scar tissue, as well as mobilization of the urethra away from the surrounding tissues. This code also includes cystourethroscopy (52000), which is sometimes performed to check the urethra after the procedure is done.

In addition, CPT indicates that if urethrolysis is performed via a retropubic rather than vaginal approach, unlisted code 53899 should be reported instead of 53500.

Medicine code changes

 

Miscellaneous services. Code 99025 [initial (new patient) visit when starred (*) surgical procedure constitutes major service at that visit] was deleted, due to the elimination of all starred procedures in CPT 2004. Thus, billing for an evaluation and management service on the same date as an office (minor) procedure will depend on the documentation. The evaluation and management service must be separate and significant from the office service. For global periods assigned to individual CPT procedures codes, coders should either reference the Medicare global periods or consult with their individual private payers, who may assign global days based on community standards.

A new instruction for 99080 [special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form] indicates that this code should not be reported with the Work Related or Medical Disability Evaluation codes 99455 and 99456, since these codes include completion of Workmen’s Compensation forms.

Additional changes to this section include:

• 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure
  
• 99050 Services requested after posted office hours in addition to basic service
  

Maternal-fetal medicine physicians, infertility specialists, gynecologic surgeons, and the folks behind HIPAA top the list of professionals cheering the updates to Current Procedural Terminology (CPT) 2004.

Among the revisions making the biggest splash for Ob/Gyns in this year’s manual:

• the addition of new codes for fetal surgical procedures—interventions that previously could be reported only with an unlisted procedure code;
  
• a new code for laparoscopic colpopexy;
  
• a revamp of the infertility lab procedure codes to incorporate advanced procedures utilizing newer technology; and
  
• the addition of the new Category II codes—necessary to bring CPT in line with HIPAA requirements, thus allowing it to remain the coding system of choice for physician services.
  

Of course, a number of other changes also may affect Ob/Gyn practice. Thus, a “best of the rest” roundup is also included.

BEST OF THE BEST

Fetal intrauterine procedures

By adding 5 new codes for fetal intrauterine surgical procedures—including an “unlisted procedure” code—to the “maternity care and delivery” section, CPT brings out of the investigational arena some techniques that can be used to treat the fetus in utero or aid in the evaluation of the fetal condition.

Note that since all of the codes include ultrasound guidance, you will not need a second code from the radiology section.

• 59070 Transabdominal amnioinfusion, including ultrasound guidance

The procedure itself involves performing an amniocentesis, then guiding the needle between the fetal extremities. Sterile saline is instilled under continuous ultrasound until adequate visualization of the fetal anatomy is possible. After the needle is removed, a detailed ultrasound of the fetus is performed. This can be coded separately by reporting 76811 (as well as 76812 if there is more than 1 fetus). Note, however, that this code would not be reported if the sterile saline is introduced via the cervix, as this is not an “invasive” procedure; instead, use the unlisted code 59899.

• 59072 Fetal umbilical cord occlusion, including ultrasound guidance

This is performed when 1 fetus in a set of monochorionic twins has a severe fetal anomaly. In the procedure, blood flow from the umbilical cord to the affected fetus is occluded, using either laser, suture, or bipolar coagulation. Ultrasound, including color Doppler, is used to confirm complete absence of flow through the occluded cord. Because the purpose of the Doppler is to check the success of the occlusion, it is not coded separately.

• 59074 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance

For these procedures, the surgeon aspirates fluid from fetal body cavities or organs to help evaluate or treat congenital abnormalities. Fetal bladder aspiration is one example; in this procedure, the physician directs the needle into the fetal bladder and aspirates fetal urine. The patient is monitored after the needle is removed and an ultrasound is performed again in about 1 hour to check for bladder refilling. Since the postprocedure ultrasound is diagnostic in nature, it can be billed for separately, but some payers may conclude that it is part of the procedure.

• 59076 Fetal shunt placement, including ultrasound guidance

This procedure involves the percutaneous placement of a double-pigtailed catheter into the area that requires drainage (the fetal bladder or the thorax, if the problem is pleural effusion). Once the catheter is in place, the other end is inserted into the amniotic cavity, so the fluid can travel into this space. The patient and fetus are monitored for an hour or longer and a repeat scan is performed to evaluate drainage and reaccumulation of amniotic fluid. In this case, the repeat scan will probably be considered part of the procedure, as it is done to check the intervention’s success.

• 59897 Unlisted fetal invasive procedure, including ultrasound guidance

Laparoscopic colpopexy

• 57425 Laparoscopy, surgical, colpopexy (suspension of vaginal apex)

With many surgeons now performing colpopexy laparoscopically, rather than abdominally, this new code (added to the “female genital system” section of “Surgical procedures”) is sure to solve some coding headaches.

For this procedure, which is normally done on patients with uterovaginal prolapse or prolapse of the vaginal vault following a hysterectomy, a Halban or McCall’s culdoplasty is performed to obliterate the cul-desac,and a graft is secured to the pubocervical and rectovaginal fascia. The physician may also do presacral dissection, so that the graft can be secured to the sacrum’s anterior longitudinal ligament. Any adhesions are lysed to gain access to the vaginal apex—this lysis is not normally coded separately.

Also changed in this section:

• 58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography or hysterosalpingography

 

Code 58340 has been revised to reflect more current terminology. The term “hysterosonography” has been changed to “saline infusion sonohysterography.” A similar change applies to the radiological supervision code 76831 [saline infusion sonohysterography, including color flow Doppler, when performed]. This change does not alter the use of the codes in any way.

Reproductive medicine procedures

This new section of laboratory codes accommodates the technologic advancements and changing practice in reproductive medicine.

The procedures are grouped into 3 categories, by type of procedure:

• Oocyte/embryo culture and fertilization techniques;
  
• Oocyte/embryo biopsy techniques; and
  
• Freezing, thawing, and storage techniques.
  

These are nonphysician procedures performed in highly specialized clinical laboratories; any physician services provided at the same time may be reported in addition. In creating this new section, codes 89252 and 89256 were deleted and renumbered to 89280/89281 and 89352, respectively.

In addition, there are 2 new Category III codes for cryopreservation of tissue and oocytes. If the procedure performed matches one of these new Category III codes, it must be reported rather than an unlisted service code. The new and revised codes can be found in the Table.

TABLE

Reproductive medicine procedures

OOCYTE/EMBRYO CULTURE AND FERTILIZATION TECHNIQUES
• 89250	Culture of oocyte(s)/embryo(s), less than 4 days;*
• 89251	with coculture of oocyte(s)/embryos†
• 89268	Insemination of oocytes
• 89272	Extended culture of oocyte(s)/embryo(s), 4-7 days‡
• 89280	Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
• 89281	greater than 10 oocytes
OOCYTE/EMBRYO BIOPSY TECHNIQUES
• 89290	Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); less than or equal to 5 embryos
• 89291	greater than 5 embryos
FREEZING, THAWING, AND STORAGE TECHNIQUES
• 89258	Cryopreservation; embryo(s)
• 89335	Cryopreservation, reproductive tissue, testicular
• 89342	Storage (per year); embryo(s)
• 89343	sperm/semen
• 89344	reproductive tissue, testicular/ovarian
• 89346	oocyte
• 89352	Thawing of cryopreserved; embryo(s)
• 89353	sperm/semen, each aliquot
• 89354	reproductive tissue, testicular/ovarian
• 89356	oocytes, each aliquot
CATEGORY III CODES
• 0058T	Cryopreservation of reproductive tissue, ovarian
• 0059T	Cryopreservation of oocyte(s)
* You can now use code 89250 to report the culture of immature oocytes. Fertilization and insemination are no longer considered part of this code, and thus are reported separately.
† Code 89251 represents the additional work of the microfertilization of more than 10 oocytes.
‡ Use code 89272 to report separate techniques for additional cultures over a 4- to 7-day period and in addition to code 89250.

Staying hip to HIPAA: Category II codes

This new section, which adds supplemental tracking codes for performance measurements, was created in an effort to comply with HIPAA regulation requirements for the code set. These codes will not affect reimbursement, but are meant to decrease the need for record abstraction and chart review. Use of these codes, it is hoped, will facilitate data collection about quality of care. Coders should be aware of the following:

• The use of these codes is optional; they may not be substituted for the regular Category I CPT codes.
  
• The codes describe components typically included in an evaluation and management service, as well as test results that are part of the laboratory test/procedure.
  
• The codes are assigned no relative value units.
  
• New codes for this section will be released semiannually. Updates can be found on the AMA/CPT Web site (www.ama-assn.org/ama/pub/category/3885.html).
  

The codes will be published in the CPT each year.

The Category II codes effective January 1, 2004, are:

• 0001FBlood pressure, measured
  
• 0002FTobacco use, smoking, assessed
  
• 0003FTobacco use, nonsmoking, assessed
  
• 0004FTobacco use cessation intervention, counseling
  
• 0005FTobacco use cessation intervention, pharmacologic therapy
  
• 0006FStatin therapy, prescribed
  
• 0007FBeta-blocker therapy, prescribed
  
• 0008FAngiotensin-converting enzyme inhibitor therapy, prescribed
  
• 0009FAnginal symptoms and level of activity, assessed
  
• 0010FAnginal symptoms and level of activity, assessed using a standardized instrument (eg, Canadian Cardiovascular Society Classification-CCSC-System, Seattle Angina Questionnaire-SAQ)
  
• 0011FOral antiplatelet therapy, prescribed (eg, aspirin, clopidogrel/Plavix, or combination of aspirin and dipyridamole/Aggrenox)
  

BEST OF THE REST

Surgical procedures Urinary system.

• 53500Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring)

This new code is for the treatment of obstructive voiding caused by periurethral scarring, which can occur following a urethral suspension procedure, such as a bladder neck suspension. The procedure associated with this new code usually involves the dissection, lysis, and removal of the periurethral scar tissue, as well as mobilization of the urethra away from the surrounding tissues. This code also includes cystourethroscopy (52000), which is sometimes performed to check the urethra after the procedure is done.

In addition, CPT indicates that if urethrolysis is performed via a retropubic rather than vaginal approach, unlisted code 53899 should be reported instead of 53500.

Medicine code changes

 

Miscellaneous services. Code 99025 [initial (new patient) visit when starred (*) surgical procedure constitutes major service at that visit] was deleted, due to the elimination of all starred procedures in CPT 2004. Thus, billing for an evaluation and management service on the same date as an office (minor) procedure will depend on the documentation. The evaluation and management service must be separate and significant from the office service. For global periods assigned to individual CPT procedures codes, coders should either reference the Medicare global periods or consult with their individual private payers, who may assign global days based on community standards.

A new instruction for 99080 [special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form] indicates that this code should not be reported with the Work Related or Medical Disability Evaluation codes 99455 and 99456, since these codes include completion of Workmen’s Compensation forms.

Additional changes to this section include:

• 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure
  
• 99050 Services requested after posted office hours in addition to basic service
  

Q Can the code for obstetric transvaginal ultrasound be used any time during the patient’s pregnancy?

A Yes. The code 76817 (ultrasound, pregnant uterus, real time with image documentation, transvaginal) does not specify a gestational period, unlike the new and revised codes 76801–76810 (for fetal and maternal evaluation either prior to or later than 14 weeks, 0 days of gestation). Thus, 76817 can be used at any time.

Q Can the code for obstetric transvaginal ultrasound be used any time during the patient’s pregnancy?

A Yes. The code 76817 (ultrasound, pregnant uterus, real time with image documentation, transvaginal) does not specify a gestational period, unlike the new and revised codes 76801–76810 (for fetal and maternal evaluation either prior to or later than 14 weeks, 0 days of gestation). Thus, 76817 can be used at any time.

Q Can the code for obstetric transvaginal ultrasound be used any time during the patient’s pregnancy?

A Yes. The code 76817 (ultrasound, pregnant uterus, real time with image documentation, transvaginal) does not specify a gestational period, unlike the new and revised codes 76801–76810 (for fetal and maternal evaluation either prior to or later than 14 weeks, 0 days of gestation). Thus, 76817 can be used at any time.

Q If we discover twins during a transvaginal ultrasound, are we allowed to bill this code twice?

A By adding new codes and revising some old ones, CPT has created a very specific set of instructions about billing for multiple gestations.

In the case of ultrasounds for fetal and maternal evaluation, CPT offers “add-on” codes to be used for each additional fetus (for example, 76802, each additional gestation [list separately in addition to the code for the primary procedure]). For limited ultrasound, we are told to essentially ignore the presence of twins for billing purposes. For follow-up ultrasound, we are instructed to bill for each gestation using modifier-59 (distinct procedure) for each additional fetus examined and documented.

Unfortunately, there are no instructions regarding the transvaginal code. Whether this was an oversight remains to be seen. I recommend erring on the conservative side and billing the transvaginal code only once if the physician is simply noting the number of gestational sacs during the scan.

Remember that although a transvaginal scan is frequently performed to check on specific factors (like fetal viability), it also may be done in conjunction with the abdominal approach to help the physician completely visualize all structures of concern. For a multiple gestation, any detailed documentation of fetal anatomy will usually come from the abdominal, not the transvaginal, scan.

Q If we discover twins during a transvaginal ultrasound, are we allowed to bill this code twice?

A By adding new codes and revising some old ones, CPT has created a very specific set of instructions about billing for multiple gestations.

In the case of ultrasounds for fetal and maternal evaluation, CPT offers “add-on” codes to be used for each additional fetus (for example, 76802, each additional gestation [list separately in addition to the code for the primary procedure]). For limited ultrasound, we are told to essentially ignore the presence of twins for billing purposes. For follow-up ultrasound, we are instructed to bill for each gestation using modifier-59 (distinct procedure) for each additional fetus examined and documented.

Unfortunately, there are no instructions regarding the transvaginal code. Whether this was an oversight remains to be seen. I recommend erring on the conservative side and billing the transvaginal code only once if the physician is simply noting the number of gestational sacs during the scan.

Remember that although a transvaginal scan is frequently performed to check on specific factors (like fetal viability), it also may be done in conjunction with the abdominal approach to help the physician completely visualize all structures of concern. For a multiple gestation, any detailed documentation of fetal anatomy will usually come from the abdominal, not the transvaginal, scan.

Q If we discover twins during a transvaginal ultrasound, are we allowed to bill this code twice?

A By adding new codes and revising some old ones, CPT has created a very specific set of instructions about billing for multiple gestations.

In the case of ultrasounds for fetal and maternal evaluation, CPT offers “add-on” codes to be used for each additional fetus (for example, 76802, each additional gestation [list separately in addition to the code for the primary procedure]). For limited ultrasound, we are told to essentially ignore the presence of twins for billing purposes. For follow-up ultrasound, we are instructed to bill for each gestation using modifier-59 (distinct procedure) for each additional fetus examined and documented.

Unfortunately, there are no instructions regarding the transvaginal code. Whether this was an oversight remains to be seen. I recommend erring on the conservative side and billing the transvaginal code only once if the physician is simply noting the number of gestational sacs during the scan.

Remember that although a transvaginal scan is frequently performed to check on specific factors (like fetal viability), it also may be done in conjunction with the abdominal approach to help the physician completely visualize all structures of concern. For a multiple gestation, any detailed documentation of fetal anatomy will usually come from the abdominal, not the transvaginal, scan.

Q One of our doctors performed a pelvic Doppler study of the ovarian vessel on a gynecologic patient with abdominal pain and an ovarian cyst. Which CPT code should we report, since there is no exact match?

A I would use code 93976 (duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study). CPT defines the duplex scan as an ultrasound that shows the pattern and direction of blood flow in arteries and veins using real-time images. This code includes color-flow Doppler mapping, if performed.

If the clinician also performed a transvaginal ultrasound to view the ovarian cyst, you may bill code 76830 (ultrasound, transvaginal) as well—just be sure there is medical justification for the second approach and the findings for that approach are documented separately.

Q One of our doctors performed a pelvic Doppler study of the ovarian vessel on a gynecologic patient with abdominal pain and an ovarian cyst. Which CPT code should we report, since there is no exact match?

A I would use code 93976 (duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study). CPT defines the duplex scan as an ultrasound that shows the pattern and direction of blood flow in arteries and veins using real-time images. This code includes color-flow Doppler mapping, if performed.

If the clinician also performed a transvaginal ultrasound to view the ovarian cyst, you may bill code 76830 (ultrasound, transvaginal) as well—just be sure there is medical justification for the second approach and the findings for that approach are documented separately.

Q One of our doctors performed a pelvic Doppler study of the ovarian vessel on a gynecologic patient with abdominal pain and an ovarian cyst. Which CPT code should we report, since there is no exact match?

A I would use code 93976 (duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study). CPT defines the duplex scan as an ultrasound that shows the pattern and direction of blood flow in arteries and veins using real-time images. This code includes color-flow Doppler mapping, if performed.

If the clinician also performed a transvaginal ultrasound to view the ovarian cyst, you may bill code 76830 (ultrasound, transvaginal) as well—just be sure there is medical justification for the second approach and the findings for that approach are documented separately.

Three of the biggest dilemmas plaguing Ob/Gyn coders in recent years have finally been tackled by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM):

• decreased libido
  
• emergency contraception
  
• premenstrual dysphoric disorder (PMDD)
  

These and other changes that went into effect October 1 may lead to significant revisions in practice encounter forms. (See Quick reference: ICD-9-CM updates.)

Just remember that some payers can take 6 months or longer to recognize new and revised codes, so be sure to find out when your payers plan to implement the updates, to avoid those troublesome “invalid diagnosis” denials.

The big 3

Decreased libido. This first change is exciting not only to coders, but also to physicians, who have long lobbied for such an update.

Until now, ICD-9 listed the code for decreased libido in its mental health chapter. Ob/Gyns frequently counsel patients on this condition, but—as many Ob/Gyn coders can attest—the mental health code made recouping payment difficult, due to a perceived “mismatch” of services on the part of payers. The new code 799.81 can be assigned for visits associated with complaints of decreased libido or sexual desire.

This change recognizes that this symptom needs to be investigated before the woman is labeled as mentally ill.

Emergency contraception. Before this year no code existed for emergency contraception, making it difficult for billers to describe to payers the nature of these encounters. A new code, V25.03, can be assigned for visits involving emergency or postcoital contraception or counseling.

PMDD. Like emergency contraception, until this year PMDD was never referenced in the ICD-9-CM codebook. But now PMDD has been added as an inclusion term to code 625.4 (premenstrual tension syndrome), and the acronym will be directly referenced in the alphabetic index. This update makes it clear that premenstrual tension syndrome and PMDD are related conditions that are coded the same.

Urgency is the intense feeling of having to urinate; urge incontinence is this feeling plus an inability to make it to the bathroom.

Other notable changes

These code changes might not have the impact of the modifications listed above, but Ob/Gyn coders would do well to familiarize themselves with the following updates.

Peripartum cardiomyopathy. ICD-9-CM has added a new code for this condition: 674.5X. Peripartum cardiomyopathy refers to cardiac failure due to heart muscle disease in the period before, during, or after delivery.

As with all obstetric chapter codes, this will require a fifth digit; for this new code, there are 5 to choose from:

• 0 (unspecified as to episode of care or not applicable),
  
• 1 (delivered, with or without mention of antepartum condition),
  
• 2 (delivered, with mention of postpartum complication),
  
• 3 (antepartum condition or complication), or
  
• 4 (postpartum condition or complication).
  

Although this code lists “postpartum cardiomyopathy” as an inclusion term, it may be used when the event occurs during the antepartum period (as evidenced by the fifth digit of 3).

Note that this condition was formerly referenced to 674.8X (postpartum cardiopathy); practice encounter forms may need revision to capture the new diagnosis.

Pelvic peritoneal adhesions in the gravida. For coders wondering which ICD-9 code to assign to a pregnant patient with pelvic peritoneal adhesions, the alphabetic index now specifically references code 648.9X (other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium).

Severe acute respiratory syndrome (SARS). 079.82 is reported for SARS-associated coronavirus; 480.3 is assigned to pneumonia due to SARS-associated coronavirus; V01.82 is reported if the patient is exposed to SARS-associated coronavirus.

Note that if a pregnant patient exposed to SARS is being monitored for the condition, use V22.2 (pregnancy incidental) plus V01.82. If the patient is being tested for the SARS virus, use code V73.89 (special screening examination for other specified viral diseases). You would not report an Ob-chapter ICD-9 code unless the patient developed SARS or SARS-like symptoms.

Obesity. The inclusion term “severe obesity” has been added to the existing code 278.01 (morbid obesity).

In general, morbid obesity refers to a patient who is over her ideal body weight by 50% to 100% or 100 pounds, or who has a body mass index greater than 39. Severe obesity usually refers to a patient who is more than 100 pounds overweight. These terms are sometimes used interchangeably and this update clarifies that 278.01 would be reported for either term used by the physician.

 

Factor V Leiden mutation. This condition can now be reported using the new code 289.81 (primary hypercoagulable state). The old code 289.8 was expanded to differentiate between inherited conditions (289.81) and predominately acquired conditions (289.82).

Urgency of urination. This common symptom is not the same as urge incontinence. Urgency is the intense feeling of having to urinate; urge incontinence, on the other hand, is the intense feeling of having to urinate but being unable to make it to the bathroom. Because of this difference, the American Urological Association requested and was granted the new code 788.63 (urgency of urination).

Abnormal glucose. In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recommended designation of a new stage of impaired glucose condition, impaired fasting glucose.¹

A new code was requested to help identify patients with this disorder. Thus, the old code (790.2) has been expanded to 3 codes:

• 790.21, impaired fasting glucose
  
• 790.22, impaired glucose tolerance test
  
• 790.29, other abnormal glucose
  

The latter code includes an abnormal nonfasting glucose result.

Billing staff should make special note of this change since the old 3-digit code, frequently found on practice encounter forms, is invalid as of October 1, 2003.

Injury. Code 959.1 has been expanded to several 5-digit codes, to capture specific sites of trunk injury.

Use:

• 959.11 for injuries to the breast
  
• 959.12 for injuries to the abdomen
  
• 959.14 for injuries to the external genitalia (also referred to as the vulva, which includes the mons pubis, the labia majora and minora, the clitoris, the vestibule of the vagina and its glands, and the opening of the urethra and vagina)
  
• 959.19 (other injury of other sites of trunk, not otherwise specified) for injuries to the groin, buttock, or perineum.
  

Need for prophylactic vaccination. The code V04.8 (need for prophylactic vaccination and inoculation against influenza) has been expanded to 3 new codes. Report:

• V04.81 for patients receiving the influenza vaccine
  
• V04.82 for children receiving vaccination against respiratory syncytial virus
  
• V04.89 for patients receiving vaccination for other viral diseases
  

The code for a laparoscopic surgical procedure converted to an open procedure has been expanded to include other surgical procedures converted to open.

Long-term current drug use. Several new codes were added to this V58.6 code category. Assign:

• V58.63 for use of antiplatelets or antithrombotics
  
• V58.64 for the use of nonsteroidal antiinflammatories
  
• V58.65 for the long-term use of steroids
  

Converted procedures. The old code V64.4 (laparoscopic surgical procedure converted to open procedure) has been expanded to include other closed surgical procedures converted to open procedures. You must now use V64.41 to report the converted laparoscopy.

Other persons seeking consultation. V65.1 (person consulting on behalf of another person) has been expanded to 2 codes:

• V65.11 denotes a visit to the pediatrician made by the pregnant mother
  
• V65.19 covers all other situations in which the person consulting with the physician is not the patient and the patient is not present.
  

Three of the biggest dilemmas plaguing Ob/Gyn coders in recent years have finally been tackled by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM):

• decreased libido
  
• emergency contraception
  
• premenstrual dysphoric disorder (PMDD)
  

These and other changes that went into effect October 1 may lead to significant revisions in practice encounter forms. (See Quick reference: ICD-9-CM updates.)

Just remember that some payers can take 6 months or longer to recognize new and revised codes, so be sure to find out when your payers plan to implement the updates, to avoid those troublesome “invalid diagnosis” denials.

The big 3

Decreased libido. This first change is exciting not only to coders, but also to physicians, who have long lobbied for such an update.

Until now, ICD-9 listed the code for decreased libido in its mental health chapter. Ob/Gyns frequently counsel patients on this condition, but—as many Ob/Gyn coders can attest—the mental health code made recouping payment difficult, due to a perceived “mismatch” of services on the part of payers. The new code 799.81 can be assigned for visits associated with complaints of decreased libido or sexual desire.

This change recognizes that this symptom needs to be investigated before the woman is labeled as mentally ill.

Emergency contraception. Before this year no code existed for emergency contraception, making it difficult for billers to describe to payers the nature of these encounters. A new code, V25.03, can be assigned for visits involving emergency or postcoital contraception or counseling.

PMDD. Like emergency contraception, until this year PMDD was never referenced in the ICD-9-CM codebook. But now PMDD has been added as an inclusion term to code 625.4 (premenstrual tension syndrome), and the acronym will be directly referenced in the alphabetic index. This update makes it clear that premenstrual tension syndrome and PMDD are related conditions that are coded the same.

Urgency is the intense feeling of having to urinate; urge incontinence is this feeling plus an inability to make it to the bathroom.

Other notable changes

These code changes might not have the impact of the modifications listed above, but Ob/Gyn coders would do well to familiarize themselves with the following updates.

Peripartum cardiomyopathy. ICD-9-CM has added a new code for this condition: 674.5X. Peripartum cardiomyopathy refers to cardiac failure due to heart muscle disease in the period before, during, or after delivery.

As with all obstetric chapter codes, this will require a fifth digit; for this new code, there are 5 to choose from:

• 0 (unspecified as to episode of care or not applicable),
  
• 1 (delivered, with or without mention of antepartum condition),
  
• 2 (delivered, with mention of postpartum complication),
  
• 3 (antepartum condition or complication), or
  
• 4 (postpartum condition or complication).
  

Although this code lists “postpartum cardiomyopathy” as an inclusion term, it may be used when the event occurs during the antepartum period (as evidenced by the fifth digit of 3).

Note that this condition was formerly referenced to 674.8X (postpartum cardiopathy); practice encounter forms may need revision to capture the new diagnosis.

Pelvic peritoneal adhesions in the gravida. For coders wondering which ICD-9 code to assign to a pregnant patient with pelvic peritoneal adhesions, the alphabetic index now specifically references code 648.9X (other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium).

Severe acute respiratory syndrome (SARS). 079.82 is reported for SARS-associated coronavirus; 480.3 is assigned to pneumonia due to SARS-associated coronavirus; V01.82 is reported if the patient is exposed to SARS-associated coronavirus.

Note that if a pregnant patient exposed to SARS is being monitored for the condition, use V22.2 (pregnancy incidental) plus V01.82. If the patient is being tested for the SARS virus, use code V73.89 (special screening examination for other specified viral diseases). You would not report an Ob-chapter ICD-9 code unless the patient developed SARS or SARS-like symptoms.

Obesity. The inclusion term “severe obesity” has been added to the existing code 278.01 (morbid obesity).

In general, morbid obesity refers to a patient who is over her ideal body weight by 50% to 100% or 100 pounds, or who has a body mass index greater than 39. Severe obesity usually refers to a patient who is more than 100 pounds overweight. These terms are sometimes used interchangeably and this update clarifies that 278.01 would be reported for either term used by the physician.

 

Factor V Leiden mutation. This condition can now be reported using the new code 289.81 (primary hypercoagulable state). The old code 289.8 was expanded to differentiate between inherited conditions (289.81) and predominately acquired conditions (289.82).

Urgency of urination. This common symptom is not the same as urge incontinence. Urgency is the intense feeling of having to urinate; urge incontinence, on the other hand, is the intense feeling of having to urinate but being unable to make it to the bathroom. Because of this difference, the American Urological Association requested and was granted the new code 788.63 (urgency of urination).

Abnormal glucose. In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recommended designation of a new stage of impaired glucose condition, impaired fasting glucose.¹

A new code was requested to help identify patients with this disorder. Thus, the old code (790.2) has been expanded to 3 codes:

• 790.21, impaired fasting glucose
  
• 790.22, impaired glucose tolerance test
  
• 790.29, other abnormal glucose
  

The latter code includes an abnormal nonfasting glucose result.

Billing staff should make special note of this change since the old 3-digit code, frequently found on practice encounter forms, is invalid as of October 1, 2003.

Injury. Code 959.1 has been expanded to several 5-digit codes, to capture specific sites of trunk injury.

Use:

• 959.11 for injuries to the breast
  
• 959.12 for injuries to the abdomen
  
• 959.14 for injuries to the external genitalia (also referred to as the vulva, which includes the mons pubis, the labia majora and minora, the clitoris, the vestibule of the vagina and its glands, and the opening of the urethra and vagina)
  
• 959.19 (other injury of other sites of trunk, not otherwise specified) for injuries to the groin, buttock, or perineum.
  

Need for prophylactic vaccination. The code V04.8 (need for prophylactic vaccination and inoculation against influenza) has been expanded to 3 new codes. Report:

• V04.81 for patients receiving the influenza vaccine
  
• V04.82 for children receiving vaccination against respiratory syncytial virus
  
• V04.89 for patients receiving vaccination for other viral diseases
  

The code for a laparoscopic surgical procedure converted to an open procedure has been expanded to include other surgical procedures converted to open.

Long-term current drug use. Several new codes were added to this V58.6 code category. Assign:

• V58.63 for use of antiplatelets or antithrombotics
  
• V58.64 for the use of nonsteroidal antiinflammatories
  
• V58.65 for the long-term use of steroids
  

Converted procedures. The old code V64.4 (laparoscopic surgical procedure converted to open procedure) has been expanded to include other closed surgical procedures converted to open procedures. You must now use V64.41 to report the converted laparoscopy.

Other persons seeking consultation. V65.1 (person consulting on behalf of another person) has been expanded to 2 codes:

• V65.11 denotes a visit to the pediatrician made by the pregnant mother
  
• V65.19 covers all other situations in which the person consulting with the physician is not the patient and the patient is not present.
  

Three of the biggest dilemmas plaguing Ob/Gyn coders in recent years have finally been tackled by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM):

• decreased libido
  
• emergency contraception
  
• premenstrual dysphoric disorder (PMDD)
  

These and other changes that went into effect October 1 may lead to significant revisions in practice encounter forms. (See Quick reference: ICD-9-CM updates.)

Just remember that some payers can take 6 months or longer to recognize new and revised codes, so be sure to find out when your payers plan to implement the updates, to avoid those troublesome “invalid diagnosis” denials.

The big 3

Decreased libido. This first change is exciting not only to coders, but also to physicians, who have long lobbied for such an update.

Until now, ICD-9 listed the code for decreased libido in its mental health chapter. Ob/Gyns frequently counsel patients on this condition, but—as many Ob/Gyn coders can attest—the mental health code made recouping payment difficult, due to a perceived “mismatch” of services on the part of payers. The new code 799.81 can be assigned for visits associated with complaints of decreased libido or sexual desire.

This change recognizes that this symptom needs to be investigated before the woman is labeled as mentally ill.

Emergency contraception. Before this year no code existed for emergency contraception, making it difficult for billers to describe to payers the nature of these encounters. A new code, V25.03, can be assigned for visits involving emergency or postcoital contraception or counseling.

PMDD. Like emergency contraception, until this year PMDD was never referenced in the ICD-9-CM codebook. But now PMDD has been added as an inclusion term to code 625.4 (premenstrual tension syndrome), and the acronym will be directly referenced in the alphabetic index. This update makes it clear that premenstrual tension syndrome and PMDD are related conditions that are coded the same.

Urgency is the intense feeling of having to urinate; urge incontinence is this feeling plus an inability to make it to the bathroom.

Other notable changes

These code changes might not have the impact of the modifications listed above, but Ob/Gyn coders would do well to familiarize themselves with the following updates.

Peripartum cardiomyopathy. ICD-9-CM has added a new code for this condition: 674.5X. Peripartum cardiomyopathy refers to cardiac failure due to heart muscle disease in the period before, during, or after delivery.

As with all obstetric chapter codes, this will require a fifth digit; for this new code, there are 5 to choose from:

• 0 (unspecified as to episode of care or not applicable),
  
• 1 (delivered, with or without mention of antepartum condition),
  
• 2 (delivered, with mention of postpartum complication),
  
• 3 (antepartum condition or complication), or
  
• 4 (postpartum condition or complication).
  

Although this code lists “postpartum cardiomyopathy” as an inclusion term, it may be used when the event occurs during the antepartum period (as evidenced by the fifth digit of 3).

Note that this condition was formerly referenced to 674.8X (postpartum cardiopathy); practice encounter forms may need revision to capture the new diagnosis.

Pelvic peritoneal adhesions in the gravida. For coders wondering which ICD-9 code to assign to a pregnant patient with pelvic peritoneal adhesions, the alphabetic index now specifically references code 648.9X (other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium).

Severe acute respiratory syndrome (SARS). 079.82 is reported for SARS-associated coronavirus; 480.3 is assigned to pneumonia due to SARS-associated coronavirus; V01.82 is reported if the patient is exposed to SARS-associated coronavirus.

Note that if a pregnant patient exposed to SARS is being monitored for the condition, use V22.2 (pregnancy incidental) plus V01.82. If the patient is being tested for the SARS virus, use code V73.89 (special screening examination for other specified viral diseases). You would not report an Ob-chapter ICD-9 code unless the patient developed SARS or SARS-like symptoms.

Obesity. The inclusion term “severe obesity” has been added to the existing code 278.01 (morbid obesity).

In general, morbid obesity refers to a patient who is over her ideal body weight by 50% to 100% or 100 pounds, or who has a body mass index greater than 39. Severe obesity usually refers to a patient who is more than 100 pounds overweight. These terms are sometimes used interchangeably and this update clarifies that 278.01 would be reported for either term used by the physician.

 

Factor V Leiden mutation. This condition can now be reported using the new code 289.81 (primary hypercoagulable state). The old code 289.8 was expanded to differentiate between inherited conditions (289.81) and predominately acquired conditions (289.82).

Urgency of urination. This common symptom is not the same as urge incontinence. Urgency is the intense feeling of having to urinate; urge incontinence, on the other hand, is the intense feeling of having to urinate but being unable to make it to the bathroom. Because of this difference, the American Urological Association requested and was granted the new code 788.63 (urgency of urination).

Abnormal glucose. In 1997, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recommended designation of a new stage of impaired glucose condition, impaired fasting glucose.¹

A new code was requested to help identify patients with this disorder. Thus, the old code (790.2) has been expanded to 3 codes:

• 790.21, impaired fasting glucose
  
• 790.22, impaired glucose tolerance test
  
• 790.29, other abnormal glucose
  

The latter code includes an abnormal nonfasting glucose result.

Billing staff should make special note of this change since the old 3-digit code, frequently found on practice encounter forms, is invalid as of October 1, 2003.

Injury. Code 959.1 has been expanded to several 5-digit codes, to capture specific sites of trunk injury.

Use:

• 959.11 for injuries to the breast
  
• 959.12 for injuries to the abdomen
  
• 959.14 for injuries to the external genitalia (also referred to as the vulva, which includes the mons pubis, the labia majora and minora, the clitoris, the vestibule of the vagina and its glands, and the opening of the urethra and vagina)
  
• 959.19 (other injury of other sites of trunk, not otherwise specified) for injuries to the groin, buttock, or perineum.
  

Need for prophylactic vaccination. The code V04.8 (need for prophylactic vaccination and inoculation against influenza) has been expanded to 3 new codes. Report:

• V04.81 for patients receiving the influenza vaccine
  
• V04.82 for children receiving vaccination against respiratory syncytial virus
  
• V04.89 for patients receiving vaccination for other viral diseases
  

The code for a laparoscopic surgical procedure converted to an open procedure has been expanded to include other surgical procedures converted to open.

Long-term current drug use. Several new codes were added to this V58.6 code category. Assign:

• V58.63 for use of antiplatelets or antithrombotics
  
• V58.64 for the use of nonsteroidal antiinflammatories
  
• V58.65 for the long-term use of steroids
  

Converted procedures. The old code V64.4 (laparoscopic surgical procedure converted to open procedure) has been expanded to include other closed surgical procedures converted to open procedures. You must now use V64.41 to report the converted laparoscopy.

Other persons seeking consultation. V65.1 (person consulting on behalf of another person) has been expanded to 2 codes:

• V65.11 denotes a visit to the pediatrician made by the pregnant mother
  
• V65.19 covers all other situations in which the person consulting with the physician is not the patient and the patient is not present.
  

Q Can you clarify what CPT means by “once per exam, not per element”? This note comes after the limited ultrasound code.

A The code for a limited ultrasound, 76815, is meant to describe a “quick” focused look at 1 or more of the examples listed in parentheses (fetal heart beat, placental location, fetal position, qualitative amniotic fluid volume, etc) in the nomenclature for this ultrasound code.

“Once per exam, not per element” means that 76815 is reported only 1 time for that encounter, regardless of how many of the listed examples you document and regardless of the number of fetuses present.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can you clarify what CPT means by “once per exam, not per element”? This note comes after the limited ultrasound code.

A The code for a limited ultrasound, 76815, is meant to describe a “quick” focused look at 1 or more of the examples listed in parentheses (fetal heart beat, placental location, fetal position, qualitative amniotic fluid volume, etc) in the nomenclature for this ultrasound code.

“Once per exam, not per element” means that 76815 is reported only 1 time for that encounter, regardless of how many of the listed examples you document and regardless of the number of fetuses present.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Can you clarify what CPT means by “once per exam, not per element”? This note comes after the limited ultrasound code.

A The code for a limited ultrasound, 76815, is meant to describe a “quick” focused look at 1 or more of the examples listed in parentheses (fetal heart beat, placental location, fetal position, qualitative amniotic fluid volume, etc) in the nomenclature for this ultrasound code.

“Once per exam, not per element” means that 76815 is reported only 1 time for that encounter, regardless of how many of the listed examples you document and regardless of the number of fetuses present.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If we do an ultrasound to rule out breech presentation and also to evaluate low amniotic fluid, should we code both a limited ultrasound and a follow-up ultrasound modified by-51 (multiple procedure) or -59 (distinct procedure)?

A If you are reevaluating a previously documented problem (the low amniotic fluid) and then discover or evaluate the possibility of a new one (the breech), you should be reporting only 1 code—the one with the highest relative value.

If you are billing for the complete service (technical and professional component), report code 76815 (2.39 relative value units [RVUs] as opposed to 2.35 RVUs for 76816). If you are billing for the professional service only, report 76816-26 (1.20 RVUs compared to .91 RVUs for 76815-26).

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If we do an ultrasound to rule out breech presentation and also to evaluate low amniotic fluid, should we code both a limited ultrasound and a follow-up ultrasound modified by-51 (multiple procedure) or -59 (distinct procedure)?

A If you are reevaluating a previously documented problem (the low amniotic fluid) and then discover or evaluate the possibility of a new one (the breech), you should be reporting only 1 code—the one with the highest relative value.

If you are billing for the complete service (technical and professional component), report code 76815 (2.39 relative value units [RVUs] as opposed to 2.35 RVUs for 76816). If you are billing for the professional service only, report 76816-26 (1.20 RVUs compared to .91 RVUs for 76815-26).

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q If we do an ultrasound to rule out breech presentation and also to evaluate low amniotic fluid, should we code both a limited ultrasound and a follow-up ultrasound modified by-51 (multiple procedure) or -59 (distinct procedure)?

A If you are reevaluating a previously documented problem (the low amniotic fluid) and then discover or evaluate the possibility of a new one (the breech), you should be reporting only 1 code—the one with the highest relative value.

If you are billing for the complete service (technical and professional component), report code 76815 (2.39 relative value units [RVUs] as opposed to 2.35 RVUs for 76816). If you are billing for the professional service only, report 76816-26 (1.20 RVUs compared to .91 RVUs for 76815-26).

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.