Reimbursement Advisor

It’s that time again—time to take a look at the latest round of changes in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes, which went into effect on October 1. Since the changes for 2002-2003 are numerous, with many (including 31 new diagnostic codes) directly affecting Ob/Gyn practice, it’s a good idea to review your patient encounter forms to make sure they’re up to date. Be aware, however, that some payers may wait until January 1, 2003, before processing claims with the new codes. Be sure to check with yours before implementing these changes.

Code revisions for gynecology

256.2, postablative ovarian failure. Artificial menopause (627.4) has been deleted from the “excludes” note that goes with code 256.2. If the patient is experiencing symptoms related to artificial menopause, report 627.4 along with this code.

256.3, other ovarian failure. The instructions to use an additional code for states associated with artificial menopause has been changed to read “states associated with natural menopause (627.2).”

622.1, dysplasia of cervix (uteri). Some terms have been added to the inclusion list that follows the code number. Among the conditions that now qualify for this code are cervical intraepithelial neoplasia I and II, high-grade squamous intraepithelial dysplasia (HGSIL), and low-grade squamous intraepithelial dysplasia (LGSIL).

627.2, natural menopause, and 627.4, artificial menopause. ICD-9 has now added the term “symptomatic” to these codes to differentiate them from asymptomatic menopause.

V49.81, postmenopausal status (age-related) (natural). This code’s descriptor was revised to include the term “asymptomatic” as a counterpart to the changes to 627.2 and 627.4, described above.

V58.83, encounter for therapeutic drug monitoring. A new note added to this code instructs coders to also report a second code indicating any associated long-term current drug use (V58.61–V58.69).

New codes for gynecology

795.0, nonspecific abnormal Papanicolaou smear of cervix. This has been expanded to 4 new codes with the addition of a fifth digit, to more closely match the Bethesda Pap interpretation language. (Note that a repeat Pap due to insufficient cell collection is now coded as 795.09 according to ICD-9-CM Coordination and Maintenance Committee staff. Previously, V76.2 was recommended for insufficient cells):

• 795.00 Nonspecific abnormal Papanicolaou smear of cervix, unspecified
  
• 795.01 Atypical squamous cell changes of undetermined significance favor benign (ASCUS favor benign); atypical glandular cell changes of undetermined significance favor benign (AGUS favor benign)
  
• 795.02 Atypical squamous cell changes of undetermined significance favor dysplasia (ASCUS favor dysplasia); atypical glandular cell changes of undetermined significance favor dysplasia (AGUS favor dysplasia)
  
• 795.09 Other nonspecific abnormal Papanicolaou smear of cervix:
  

• benign cellular changes
  
• unsatisfactory smear
  

998.3, disruption of operation wound. With the addition of a fifth digit, this code has been expanded to 2 new codes that allow the coder to differentiate between an external and internal wound dehiscence. An example of an external wound would be 1 from abdominal surgery; an internal wound might be vaginal cuff sutures. If the surgeon does not specify which, default to the external wound code:

• 998.31 Disruption of internal operation wound
  
• 998.32 Disruption of external operation wound; disruption of operation wound not otherwise specified
  

V13.2, other genital system and obstetric disorders. This code has been expanded to 2 new codes with the addition of a fifth digit. The American College of Obstetricians and Gynecologists (ACOG) presented this proposal, along with the 1 discussed under the obstetric code changes, to capture information about women with a history of preterm labor, which is associated with complications in future pregnancies. (Note that V13.21 is used to indicate a patient who is not currently pregnant. V13.29 would be used to indicate a past personal history of, for example, dysplasia when the current or last few Paps were normal):

• V13.21 Personal history of preterm labor
  
• V13.29 Other genital system and obstetric disorders
  

V58.42, aftercare following surgery for neoplasm. Use this code when the procedure involves neoplasms classifiable to diagnostic codes 140–239. You’ll also need another aftercare code to fully identify the reason for the encounter. For instance, was the purpose of the visit chemotherapy after the surgery (V58.1) or attention to surgical dressings (V58.3)?

 

V58.7, aftercare following surgery to specified body systems, not elsewhere classified. This new subcategory was added, along with 8 new fifth-digit codes. As with the aftercare code for neoplasm surgery, these require a more specific code to identify the reason for the encounter. Of these 8 codes, the following are the most likely to be of use to Ob/Gyns (note that code V58.76 excludes aftercare following sterilization reversal [V26.22]):

• V58.76 Aftercare following surgery of the genitourinary system, not elsewhere classified; aftercare following surgery for conditions classifiable to 520–579
  
• V58.77 Aftercare following surgery of the skin and subcutaneous tissue, not elsewhere classified; aftercare following surgery for conditions classifiable to 680–709
  

Code revisions for obstetrics

646.6X, infections of genitourinary tract in pregnancy. The note that specifies which conditions qualify for this code has been revised. “Conditions classifiable to 614–615” has been more clearly spelled out as including only 614.0–614.5 and 614.7–615.0. The code 614.6 is excluded because pelvic peritoneal adhesions do not represent an infection. If pelvic adhesions were complicating the pregnancy, the code 648.9X (other current conditions classifiable elsewhere), would be more appropriate.

674.1X, disruption of cesarean wound. An "excludes" note has been added. This code would not be reported if the patient had uterine rupture before the onset of labor (665.0X) or uterine rupture during labor (665.1X).

New codes for obstetrics

633, ectopic pregnancy. The codes in this category have been expanded to a fifth digit to describe an ectopic pregnancy by site, with or without an intrauterine pregnancy:

• 633.00 Abdominal pregnancy without intrauterine pregnancy
  
• 633.01 Abdominal pregnancy with intrauterine pregnancy
  
• 633.10 Tubal pregnancy without intrauterine pregnancy
  
• 633.11 Tubal pregnancy with intrauterine pregnancy
  
• 633.20 Ovarian pregnancy without intrauterine pregnancy
  
• 633.21 Ovarian pregnancy with intrauterine pregnancy
  
• 633.80 Other ectopic pregnancy without intrauterine pregnancy
  
• 633.81 Other ectopic pregnancy with intrauterine pregnancy
  
• 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
  
• 633.91 Unspecified ectopic pregnancy with intrauterine pregnancy
  

V23.4, pregnancy with other poor obstetric history. As with V13.2 above, this code has been expanded into 2 new codes, to be used with a current pregnancy only:

• V23.41 Pregnancy with history of preterm labor
  
• V23.49 Pregnancy with other poor obstetric history (used for a history of conditions classifiable to 630–643 and 645–676)
  

V83.8, other genetic carrier status. This new subcategory was added along with 2 new fifth-digit codes. Remember, these should be used only when the patient can pass the disease on genetically to the next generation—they are not intended for patients who might develop the disease themselves:

• V83.81 Cystic fibrosis gene carrier
  
• V83.89 Other genetic carrier status
  

Miscellaneous code revisions

New instructions. A new sequencing instruction has been added to the ICD-9. It reads, “Code, if applicable, any causal condition first.” Any code with this note may be used as a principal diagnosis if no causal condition is applicable or known. For instance, since this note appears after code category 788.3 (incontinence of urine), the coder would first code the cause of the patient’s incontinence. If it was due to genital prolapse (618.0–618.9), one of these codes would appear first on the claim. If the cause is not known, however, 788.3 is sufficient.

454.9, asymptomatic varicose veins. The descriptor for this code previously read “varicose veins of lower extremities, without mention of ulcer or inflammation.”

Miscellaneous code additions

040.82, toxic shock syndrome. A new code for this condition was added in recognition of its often-severe symptoms. This syndrome had previously been assigned as an inclusion term to the code 040.89 (other specified bacterial diseases). When assigning this, an additional code should be used to identify the organism involved.

454.8, varicose veins of the lower extremities, with other complications. This was added to fill the gap between varicose veins with ulcer and/or inflammation (454.0–454.2) and asymptomatic varicose veins (454.9). Use this code for findings of edema, swelling, or pain in conjunction with varicose veins.

795.3, nonspecific positive culture findings. This code has been expanded to 2 new codes with the addition of a fifth digit. The first of these is a reaction to the events of the past year:

• 795.31 Nonspecific positive findings for anthrax; positive findings by nasal swab
  
• 795.39 Other nonspecific positive culture findings (used for positive culture samples taken from the nose, throat, a wound or sputum)
  

V01.8, contact with or exposure to communicable diseases. This code has been expanded to 2 new codes, once again due to recent events:

• V01.81 Anthrax
  
• V01.89 Other communicable diseases
  

For more information

Coders can obtain the most current edition of ICD-9-CM from several sources: ACOG, the American Medical Association, Ingenix, Practice Management Information Corporation, and Channel Publishing, to name a few. You also can directly download a copy of the October 1, 2002 editions of ICD-9-CM Volume 1 (alphabetic index) and Volume 2 (tabular index) via the government Web site http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm. The files are in Adobe format, so you’ll need a copy of Adobe Acrobat Reader 5.0 (available for free download at http://www.adobe.com/products/acrobat/readstep2.html) to view the files.

 

Ms. Witt reports no affiliation or financial arrangement with any of the companies that manufacture drugs or devices in any of the product classes mentioned in this article.

It’s that time again—time to take a look at the latest round of changes in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes, which went into effect on October 1. Since the changes for 2002-2003 are numerous, with many (including 31 new diagnostic codes) directly affecting Ob/Gyn practice, it’s a good idea to review your patient encounter forms to make sure they’re up to date. Be aware, however, that some payers may wait until January 1, 2003, before processing claims with the new codes. Be sure to check with yours before implementing these changes.

Code revisions for gynecology

256.2, postablative ovarian failure. Artificial menopause (627.4) has been deleted from the “excludes” note that goes with code 256.2. If the patient is experiencing symptoms related to artificial menopause, report 627.4 along with this code.

256.3, other ovarian failure. The instructions to use an additional code for states associated with artificial menopause has been changed to read “states associated with natural menopause (627.2).”

622.1, dysplasia of cervix (uteri). Some terms have been added to the inclusion list that follows the code number. Among the conditions that now qualify for this code are cervical intraepithelial neoplasia I and II, high-grade squamous intraepithelial dysplasia (HGSIL), and low-grade squamous intraepithelial dysplasia (LGSIL).

627.2, natural menopause, and 627.4, artificial menopause. ICD-9 has now added the term “symptomatic” to these codes to differentiate them from asymptomatic menopause.

V49.81, postmenopausal status (age-related) (natural). This code’s descriptor was revised to include the term “asymptomatic” as a counterpart to the changes to 627.2 and 627.4, described above.

V58.83, encounter for therapeutic drug monitoring. A new note added to this code instructs coders to also report a second code indicating any associated long-term current drug use (V58.61–V58.69).

New codes for gynecology

795.0, nonspecific abnormal Papanicolaou smear of cervix. This has been expanded to 4 new codes with the addition of a fifth digit, to more closely match the Bethesda Pap interpretation language. (Note that a repeat Pap due to insufficient cell collection is now coded as 795.09 according to ICD-9-CM Coordination and Maintenance Committee staff. Previously, V76.2 was recommended for insufficient cells):

• 795.00 Nonspecific abnormal Papanicolaou smear of cervix, unspecified
  
• 795.01 Atypical squamous cell changes of undetermined significance favor benign (ASCUS favor benign); atypical glandular cell changes of undetermined significance favor benign (AGUS favor benign)
  
• 795.02 Atypical squamous cell changes of undetermined significance favor dysplasia (ASCUS favor dysplasia); atypical glandular cell changes of undetermined significance favor dysplasia (AGUS favor dysplasia)
  
• 795.09 Other nonspecific abnormal Papanicolaou smear of cervix:
  

• benign cellular changes
  
• unsatisfactory smear
  

998.3, disruption of operation wound. With the addition of a fifth digit, this code has been expanded to 2 new codes that allow the coder to differentiate between an external and internal wound dehiscence. An example of an external wound would be 1 from abdominal surgery; an internal wound might be vaginal cuff sutures. If the surgeon does not specify which, default to the external wound code:

• 998.31 Disruption of internal operation wound
  
• 998.32 Disruption of external operation wound; disruption of operation wound not otherwise specified
  

V13.2, other genital system and obstetric disorders. This code has been expanded to 2 new codes with the addition of a fifth digit. The American College of Obstetricians and Gynecologists (ACOG) presented this proposal, along with the 1 discussed under the obstetric code changes, to capture information about women with a history of preterm labor, which is associated with complications in future pregnancies. (Note that V13.21 is used to indicate a patient who is not currently pregnant. V13.29 would be used to indicate a past personal history of, for example, dysplasia when the current or last few Paps were normal):

• V13.21 Personal history of preterm labor
  
• V13.29 Other genital system and obstetric disorders
  

V58.42, aftercare following surgery for neoplasm. Use this code when the procedure involves neoplasms classifiable to diagnostic codes 140–239. You’ll also need another aftercare code to fully identify the reason for the encounter. For instance, was the purpose of the visit chemotherapy after the surgery (V58.1) or attention to surgical dressings (V58.3)?

 

V58.7, aftercare following surgery to specified body systems, not elsewhere classified. This new subcategory was added, along with 8 new fifth-digit codes. As with the aftercare code for neoplasm surgery, these require a more specific code to identify the reason for the encounter. Of these 8 codes, the following are the most likely to be of use to Ob/Gyns (note that code V58.76 excludes aftercare following sterilization reversal [V26.22]):

• V58.76 Aftercare following surgery of the genitourinary system, not elsewhere classified; aftercare following surgery for conditions classifiable to 520–579
  
• V58.77 Aftercare following surgery of the skin and subcutaneous tissue, not elsewhere classified; aftercare following surgery for conditions classifiable to 680–709
  

Code revisions for obstetrics

646.6X, infections of genitourinary tract in pregnancy. The note that specifies which conditions qualify for this code has been revised. “Conditions classifiable to 614–615” has been more clearly spelled out as including only 614.0–614.5 and 614.7–615.0. The code 614.6 is excluded because pelvic peritoneal adhesions do not represent an infection. If pelvic adhesions were complicating the pregnancy, the code 648.9X (other current conditions classifiable elsewhere), would be more appropriate.

674.1X, disruption of cesarean wound. An "excludes" note has been added. This code would not be reported if the patient had uterine rupture before the onset of labor (665.0X) or uterine rupture during labor (665.1X).

New codes for obstetrics

633, ectopic pregnancy. The codes in this category have been expanded to a fifth digit to describe an ectopic pregnancy by site, with or without an intrauterine pregnancy:

• 633.00 Abdominal pregnancy without intrauterine pregnancy
  
• 633.01 Abdominal pregnancy with intrauterine pregnancy
  
• 633.10 Tubal pregnancy without intrauterine pregnancy
  
• 633.11 Tubal pregnancy with intrauterine pregnancy
  
• 633.20 Ovarian pregnancy without intrauterine pregnancy
  
• 633.21 Ovarian pregnancy with intrauterine pregnancy
  
• 633.80 Other ectopic pregnancy without intrauterine pregnancy
  
• 633.81 Other ectopic pregnancy with intrauterine pregnancy
  
• 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
  
• 633.91 Unspecified ectopic pregnancy with intrauterine pregnancy
  

V23.4, pregnancy with other poor obstetric history. As with V13.2 above, this code has been expanded into 2 new codes, to be used with a current pregnancy only:

• V23.41 Pregnancy with history of preterm labor
  
• V23.49 Pregnancy with other poor obstetric history (used for a history of conditions classifiable to 630–643 and 645–676)
  

V83.8, other genetic carrier status. This new subcategory was added along with 2 new fifth-digit codes. Remember, these should be used only when the patient can pass the disease on genetically to the next generation—they are not intended for patients who might develop the disease themselves:

• V83.81 Cystic fibrosis gene carrier
  
• V83.89 Other genetic carrier status
  

Miscellaneous code revisions

New instructions. A new sequencing instruction has been added to the ICD-9. It reads, “Code, if applicable, any causal condition first.” Any code with this note may be used as a principal diagnosis if no causal condition is applicable or known. For instance, since this note appears after code category 788.3 (incontinence of urine), the coder would first code the cause of the patient’s incontinence. If it was due to genital prolapse (618.0–618.9), one of these codes would appear first on the claim. If the cause is not known, however, 788.3 is sufficient.

454.9, asymptomatic varicose veins. The descriptor for this code previously read “varicose veins of lower extremities, without mention of ulcer or inflammation.”

Miscellaneous code additions

040.82, toxic shock syndrome. A new code for this condition was added in recognition of its often-severe symptoms. This syndrome had previously been assigned as an inclusion term to the code 040.89 (other specified bacterial diseases). When assigning this, an additional code should be used to identify the organism involved.

454.8, varicose veins of the lower extremities, with other complications. This was added to fill the gap between varicose veins with ulcer and/or inflammation (454.0–454.2) and asymptomatic varicose veins (454.9). Use this code for findings of edema, swelling, or pain in conjunction with varicose veins.

795.3, nonspecific positive culture findings. This code has been expanded to 2 new codes with the addition of a fifth digit. The first of these is a reaction to the events of the past year:

• 795.31 Nonspecific positive findings for anthrax; positive findings by nasal swab
  
• 795.39 Other nonspecific positive culture findings (used for positive culture samples taken from the nose, throat, a wound or sputum)
  

V01.8, contact with or exposure to communicable diseases. This code has been expanded to 2 new codes, once again due to recent events:

• V01.81 Anthrax
  
• V01.89 Other communicable diseases
  

For more information

Coders can obtain the most current edition of ICD-9-CM from several sources: ACOG, the American Medical Association, Ingenix, Practice Management Information Corporation, and Channel Publishing, to name a few. You also can directly download a copy of the October 1, 2002 editions of ICD-9-CM Volume 1 (alphabetic index) and Volume 2 (tabular index) via the government Web site http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm. The files are in Adobe format, so you’ll need a copy of Adobe Acrobat Reader 5.0 (available for free download at http://www.adobe.com/products/acrobat/readstep2.html) to view the files.

 

Ms. Witt reports no affiliation or financial arrangement with any of the companies that manufacture drugs or devices in any of the product classes mentioned in this article.

It’s that time again—time to take a look at the latest round of changes in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes, which went into effect on October 1. Since the changes for 2002-2003 are numerous, with many (including 31 new diagnostic codes) directly affecting Ob/Gyn practice, it’s a good idea to review your patient encounter forms to make sure they’re up to date. Be aware, however, that some payers may wait until January 1, 2003, before processing claims with the new codes. Be sure to check with yours before implementing these changes.

Code revisions for gynecology

256.2, postablative ovarian failure. Artificial menopause (627.4) has been deleted from the “excludes” note that goes with code 256.2. If the patient is experiencing symptoms related to artificial menopause, report 627.4 along with this code.

256.3, other ovarian failure. The instructions to use an additional code for states associated with artificial menopause has been changed to read “states associated with natural menopause (627.2).”

622.1, dysplasia of cervix (uteri). Some terms have been added to the inclusion list that follows the code number. Among the conditions that now qualify for this code are cervical intraepithelial neoplasia I and II, high-grade squamous intraepithelial dysplasia (HGSIL), and low-grade squamous intraepithelial dysplasia (LGSIL).

627.2, natural menopause, and 627.4, artificial menopause. ICD-9 has now added the term “symptomatic” to these codes to differentiate them from asymptomatic menopause.

V49.81, postmenopausal status (age-related) (natural). This code’s descriptor was revised to include the term “asymptomatic” as a counterpart to the changes to 627.2 and 627.4, described above.

V58.83, encounter for therapeutic drug monitoring. A new note added to this code instructs coders to also report a second code indicating any associated long-term current drug use (V58.61–V58.69).

New codes for gynecology

795.0, nonspecific abnormal Papanicolaou smear of cervix. This has been expanded to 4 new codes with the addition of a fifth digit, to more closely match the Bethesda Pap interpretation language. (Note that a repeat Pap due to insufficient cell collection is now coded as 795.09 according to ICD-9-CM Coordination and Maintenance Committee staff. Previously, V76.2 was recommended for insufficient cells):

• 795.00 Nonspecific abnormal Papanicolaou smear of cervix, unspecified
  
• 795.01 Atypical squamous cell changes of undetermined significance favor benign (ASCUS favor benign); atypical glandular cell changes of undetermined significance favor benign (AGUS favor benign)
  
• 795.02 Atypical squamous cell changes of undetermined significance favor dysplasia (ASCUS favor dysplasia); atypical glandular cell changes of undetermined significance favor dysplasia (AGUS favor dysplasia)
  
• 795.09 Other nonspecific abnormal Papanicolaou smear of cervix:
  

• benign cellular changes
  
• unsatisfactory smear
  

998.3, disruption of operation wound. With the addition of a fifth digit, this code has been expanded to 2 new codes that allow the coder to differentiate between an external and internal wound dehiscence. An example of an external wound would be 1 from abdominal surgery; an internal wound might be vaginal cuff sutures. If the surgeon does not specify which, default to the external wound code:

• 998.31 Disruption of internal operation wound
  
• 998.32 Disruption of external operation wound; disruption of operation wound not otherwise specified
  

V13.2, other genital system and obstetric disorders. This code has been expanded to 2 new codes with the addition of a fifth digit. The American College of Obstetricians and Gynecologists (ACOG) presented this proposal, along with the 1 discussed under the obstetric code changes, to capture information about women with a history of preterm labor, which is associated with complications in future pregnancies. (Note that V13.21 is used to indicate a patient who is not currently pregnant. V13.29 would be used to indicate a past personal history of, for example, dysplasia when the current or last few Paps were normal):

• V13.21 Personal history of preterm labor
  
• V13.29 Other genital system and obstetric disorders
  

V58.42, aftercare following surgery for neoplasm. Use this code when the procedure involves neoplasms classifiable to diagnostic codes 140–239. You’ll also need another aftercare code to fully identify the reason for the encounter. For instance, was the purpose of the visit chemotherapy after the surgery (V58.1) or attention to surgical dressings (V58.3)?

 

V58.7, aftercare following surgery to specified body systems, not elsewhere classified. This new subcategory was added, along with 8 new fifth-digit codes. As with the aftercare code for neoplasm surgery, these require a more specific code to identify the reason for the encounter. Of these 8 codes, the following are the most likely to be of use to Ob/Gyns (note that code V58.76 excludes aftercare following sterilization reversal [V26.22]):

• V58.76 Aftercare following surgery of the genitourinary system, not elsewhere classified; aftercare following surgery for conditions classifiable to 520–579
  
• V58.77 Aftercare following surgery of the skin and subcutaneous tissue, not elsewhere classified; aftercare following surgery for conditions classifiable to 680–709
  

Code revisions for obstetrics

646.6X, infections of genitourinary tract in pregnancy. The note that specifies which conditions qualify for this code has been revised. “Conditions classifiable to 614–615” has been more clearly spelled out as including only 614.0–614.5 and 614.7–615.0. The code 614.6 is excluded because pelvic peritoneal adhesions do not represent an infection. If pelvic adhesions were complicating the pregnancy, the code 648.9X (other current conditions classifiable elsewhere), would be more appropriate.

674.1X, disruption of cesarean wound. An "excludes" note has been added. This code would not be reported if the patient had uterine rupture before the onset of labor (665.0X) or uterine rupture during labor (665.1X).

New codes for obstetrics

633, ectopic pregnancy. The codes in this category have been expanded to a fifth digit to describe an ectopic pregnancy by site, with or without an intrauterine pregnancy:

• 633.00 Abdominal pregnancy without intrauterine pregnancy
  
• 633.01 Abdominal pregnancy with intrauterine pregnancy
  
• 633.10 Tubal pregnancy without intrauterine pregnancy
  
• 633.11 Tubal pregnancy with intrauterine pregnancy
  
• 633.20 Ovarian pregnancy without intrauterine pregnancy
  
• 633.21 Ovarian pregnancy with intrauterine pregnancy
  
• 633.80 Other ectopic pregnancy without intrauterine pregnancy
  
• 633.81 Other ectopic pregnancy with intrauterine pregnancy
  
• 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
  
• 633.91 Unspecified ectopic pregnancy with intrauterine pregnancy
  

V23.4, pregnancy with other poor obstetric history. As with V13.2 above, this code has been expanded into 2 new codes, to be used with a current pregnancy only:

• V23.41 Pregnancy with history of preterm labor
  
• V23.49 Pregnancy with other poor obstetric history (used for a history of conditions classifiable to 630–643 and 645–676)
  

V83.8, other genetic carrier status. This new subcategory was added along with 2 new fifth-digit codes. Remember, these should be used only when the patient can pass the disease on genetically to the next generation—they are not intended for patients who might develop the disease themselves:

• V83.81 Cystic fibrosis gene carrier
  
• V83.89 Other genetic carrier status
  

Miscellaneous code revisions

New instructions. A new sequencing instruction has been added to the ICD-9. It reads, “Code, if applicable, any causal condition first.” Any code with this note may be used as a principal diagnosis if no causal condition is applicable or known. For instance, since this note appears after code category 788.3 (incontinence of urine), the coder would first code the cause of the patient’s incontinence. If it was due to genital prolapse (618.0–618.9), one of these codes would appear first on the claim. If the cause is not known, however, 788.3 is sufficient.

454.9, asymptomatic varicose veins. The descriptor for this code previously read “varicose veins of lower extremities, without mention of ulcer or inflammation.”

Miscellaneous code additions

040.82, toxic shock syndrome. A new code for this condition was added in recognition of its often-severe symptoms. This syndrome had previously been assigned as an inclusion term to the code 040.89 (other specified bacterial diseases). When assigning this, an additional code should be used to identify the organism involved.

454.8, varicose veins of the lower extremities, with other complications. This was added to fill the gap between varicose veins with ulcer and/or inflammation (454.0–454.2) and asymptomatic varicose veins (454.9). Use this code for findings of edema, swelling, or pain in conjunction with varicose veins.

795.3, nonspecific positive culture findings. This code has been expanded to 2 new codes with the addition of a fifth digit. The first of these is a reaction to the events of the past year:

• 795.31 Nonspecific positive findings for anthrax; positive findings by nasal swab
  
• 795.39 Other nonspecific positive culture findings (used for positive culture samples taken from the nose, throat, a wound or sputum)
  

V01.8, contact with or exposure to communicable diseases. This code has been expanded to 2 new codes, once again due to recent events:

• V01.81 Anthrax
  
• V01.89 Other communicable diseases
  

For more information

Coders can obtain the most current edition of ICD-9-CM from several sources: ACOG, the American Medical Association, Ingenix, Practice Management Information Corporation, and Channel Publishing, to name a few. You also can directly download a copy of the October 1, 2002 editions of ICD-9-CM Volume 1 (alphabetic index) and Volume 2 (tabular index) via the government Web site http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm. The files are in Adobe format, so you’ll need a copy of Adobe Acrobat Reader 5.0 (available for free download at http://www.adobe.com/products/acrobat/readstep2.html) to view the files.

 

Ms. Witt reports no affiliation or financial arrangement with any of the companies that manufacture drugs or devices in any of the product classes mentioned in this article.

Q A patient who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO) had multiple severe postoperative complications (hypotension, acute renal failure with anuria, hypokalemia, and a broken humerus due to a fall sustained while trying to get out of bed). As a result, the physician spent 2 to 4 hours per day with the woman, but she was not transferred to the intensive care or critical care units (ICU/CCU). How can we get reimbursed for the extra time spent with the patient?

A First, it is important to know if the surgeon who operated and the physician who provided postoperative care for the complications are one and the same. If so, and if the problems were related to the TAH/BSO, the payer (e.g., Medicare) may include the postoperative care in the global fee, even if the physician spent more time with the patient each day than is typical. If the documentation clearly shows care of these problems were not related to the TAH/BSO, bill the inpatient hospital E/M services code and add the modifier -24.

You also can use the prolonged-services codes (99356 to 99357) for face-to-face contact—as well as the subsequent hospital care service—if the time was carefully documented.

Also consider the Critical Care services codes (99291 to 99292), as there is no requirement that the patient be admitted to the ICU or CCU to report them. However, the patient would have to meet the CPT definition of critically ill or injured.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 A patient who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO) had multiple severe postoperative complications (hypotension, acute renal failure with anuria, hypokalemia, and a broken humerus due to a fall sustained while trying to get out of bed). As a result, the physician spent 2 to 4 hours per day with the woman, but she was not transferred to the intensive care or critical care units (ICU/CCU). How can we get reimbursed for the extra time spent with the patient?

A First, it is important to know if the surgeon who operated and the physician who provided postoperative care for the complications are one and the same. If so, and if the problems were related to the TAH/BSO, the payer (e.g., Medicare) may include the postoperative care in the global fee, even if the physician spent more time with the patient each day than is typical. If the documentation clearly shows care of these problems were not related to the TAH/BSO, bill the inpatient hospital E/M services code and add the modifier -24.

You also can use the prolonged-services codes (99356 to 99357) for face-to-face contact—as well as the subsequent hospital care service—if the time was carefully documented.

Also consider the Critical Care services codes (99291 to 99292), as there is no requirement that the patient be admitted to the ICU or CCU to report them. However, the patient would have to meet the CPT definition of critically ill or injured.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 A patient who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO) had multiple severe postoperative complications (hypotension, acute renal failure with anuria, hypokalemia, and a broken humerus due to a fall sustained while trying to get out of bed). As a result, the physician spent 2 to 4 hours per day with the woman, but she was not transferred to the intensive care or critical care units (ICU/CCU). How can we get reimbursed for the extra time spent with the patient?

A First, it is important to know if the surgeon who operated and the physician who provided postoperative care for the complications are one and the same. If so, and if the problems were related to the TAH/BSO, the payer (e.g., Medicare) may include the postoperative care in the global fee, even if the physician spent more time with the patient each day than is typical. If the documentation clearly shows care of these problems were not related to the TAH/BSO, bill the inpatient hospital E/M services code and add the modifier -24.

You also can use the prolonged-services codes (99356 to 99357) for face-to-face contact—as well as the subsequent hospital care service—if the time was carefully documented.

Also consider the Critical Care services codes (99291 to 99292), as there is no requirement that the patient be admitted to the ICU or CCU to report them. However, the patient would have to meet the CPT definition of critically ill or injured.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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.

<huc>Q</huc> How do I bill for patient counseling on contraception when no exam was performed? An insurance carrier has denied the code 99211 with V25.49.

<huc>A</huc> The diagnostic code V25.49 implies the patient already has been placed on a contraceptive other than birth control pills (an IUD or implantable device). If you are counseling a patient prior to initiating contraceptives, use a code from the V25.0 category (general counseling and advice).

Further, the code 99211 describes a minimal E/M service. If the physician or a nonphysician practitioner saw the patient and took a history before determining her options, this level of service would be incorrect. In fact, contraceptive counseling is actually a “preventive” service. Therefore, the preventive medicine counseling codes (99401 to 99404) are more appropriate. Bear in mind that to use these codes, you must know the length of time you spent counseling the patient. For instance, the documentation for code 99401 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) should include the content of the counseling session and the time spent. However, some payers do not cover contraceptive management, making the patient responsible for the bill. When in doubt, check with your individual payer.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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.

<huc>Q</huc> How do I bill for patient counseling on contraception when no exam was performed? An insurance carrier has denied the code 99211 with V25.49.

<huc>A</huc> The diagnostic code V25.49 implies the patient already has been placed on a contraceptive other than birth control pills (an IUD or implantable device). If you are counseling a patient prior to initiating contraceptives, use a code from the V25.0 category (general counseling and advice).

Further, the code 99211 describes a minimal E/M service. If the physician or a nonphysician practitioner saw the patient and took a history before determining her options, this level of service would be incorrect. In fact, contraceptive counseling is actually a “preventive” service. Therefore, the preventive medicine counseling codes (99401 to 99404) are more appropriate. Bear in mind that to use these codes, you must know the length of time you spent counseling the patient. For instance, the documentation for code 99401 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) should include the content of the counseling session and the time spent. However, some payers do not cover contraceptive management, making the patient responsible for the bill. When in doubt, check with your individual payer.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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.

<huc>Q</huc> How do I bill for patient counseling on contraception when no exam was performed? An insurance carrier has denied the code 99211 with V25.49.

<huc>A</huc> The diagnostic code V25.49 implies the patient already has been placed on a contraceptive other than birth control pills (an IUD or implantable device). If you are counseling a patient prior to initiating contraceptives, use a code from the V25.0 category (general counseling and advice).

Further, the code 99211 describes a minimal E/M service. If the physician or a nonphysician practitioner saw the patient and took a history before determining her options, this level of service would be incorrect. In fact, contraceptive counseling is actually a “preventive” service. Therefore, the preventive medicine counseling codes (99401 to 99404) are more appropriate. Bear in mind that to use these codes, you must know the length of time you spent counseling the patient. For instance, the documentation for code 99401 (preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) should include the content of the counseling session and the time spent. However, some payers do not cover contraceptive management, making the patient responsible for the bill. When in doubt, check with your individual payer.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 After having a total vaginal hysterectomy with anterioposterior (A&P) repair performed by another physician a year ago, a new patient presented to my practice with persistent spotting. I noted that a nonabsorbable suture was used in the vaginal cuff, and therefore resected the tail of the suture. I removed the protruding stitch that seemed to be causing the problem. Which codes should I use for the diagnosis and the procedure?

A Because the complication was the result of previous surgery, consider using 909.3 (late effect of complications of surgical and medical care) and 998.83 (other specified complications of procedures not elsewhere classified) to describe the suture that was causing the irritation. Or, if you think the problem with the suture was more closely related to disruption of the wound, use 998.3 as the second code instead of 998.83.

As for the suture removal, bill an E/M service because CPT only allows physicians to report suture removal as a surgical procedure when a regional block or general anesthesia is administered (15851, removal of sutures under anesthesia [other than local]), with another surgeon. (Note, however, that some payers only allow the use of this code with general anesthesia). If you replaced the suture after removing the original, bill 57200 (suture of vagina) in addition to the E/M service, and use the modifier -25 to indicate that the E/M service was significant and separate from the procedure.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 After having a total vaginal hysterectomy with anterioposterior (A&P) repair performed by another physician a year ago, a new patient presented to my practice with persistent spotting. I noted that a nonabsorbable suture was used in the vaginal cuff, and therefore resected the tail of the suture. I removed the protruding stitch that seemed to be causing the problem. Which codes should I use for the diagnosis and the procedure?

A Because the complication was the result of previous surgery, consider using 909.3 (late effect of complications of surgical and medical care) and 998.83 (other specified complications of procedures not elsewhere classified) to describe the suture that was causing the irritation. Or, if you think the problem with the suture was more closely related to disruption of the wound, use 998.3 as the second code instead of 998.83.

As for the suture removal, bill an E/M service because CPT only allows physicians to report suture removal as a surgical procedure when a regional block or general anesthesia is administered (15851, removal of sutures under anesthesia [other than local]), with another surgeon. (Note, however, that some payers only allow the use of this code with general anesthesia). If you replaced the suture after removing the original, bill 57200 (suture of vagina) in addition to the E/M service, and use the modifier -25 to indicate that the E/M service was significant and separate from the procedure.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 After having a total vaginal hysterectomy with anterioposterior (A&P) repair performed by another physician a year ago, a new patient presented to my practice with persistent spotting. I noted that a nonabsorbable suture was used in the vaginal cuff, and therefore resected the tail of the suture. I removed the protruding stitch that seemed to be causing the problem. Which codes should I use for the diagnosis and the procedure?

A Because the complication was the result of previous surgery, consider using 909.3 (late effect of complications of surgical and medical care) and 998.83 (other specified complications of procedures not elsewhere classified) to describe the suture that was causing the irritation. Or, if you think the problem with the suture was more closely related to disruption of the wound, use 998.3 as the second code instead of 998.83.

As for the suture removal, bill an E/M service because CPT only allows physicians to report suture removal as a surgical procedure when a regional block or general anesthesia is administered (15851, removal of sutures under anesthesia [other than local]), with another surgeon. (Note, however, that some payers only allow the use of this code with general anesthesia). If you replaced the suture after removing the original, bill 57200 (suture of vagina) in addition to the E/M service, and use the modifier -25 to indicate that the E/M service was significant and separate from the procedure.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Many patients in our practice see their family physician (FP) for prenatal care. Our obstetrician then performs the delivery and inpatient postpartum care, and the FP handles the outpatient postpartum care in the clinic. The dilemma arises when a cesarean delivery is performed and the FP’s office bills 59430, a postpartum care-only code that includes both inpatient and outpatient care. How should the Ob bill for his services?

A Unfortunately, the cesarean delivery-only codes (59514 and 59620 for failed VBAC) do not include any postpartum care, and the cesarean delivery plus postpartum care codes (59515 and 59622) include both inpatient and outpatient postpartum care, per the ACOG Coding Manual. However, in the case you described, you need to communicate to the payer that the postpartum care was divided between the obstetrician and the FP. Otherwise, some payers might deny the service billed by the FP or inquire why the Ob billed for a service not provided.

One way to avoid this dilemma: Bill for the cesarean delivery plus the postpartum care using the code 59515 or 59622 and add the modifier -52; be sure to carefully document which part of the service (i.e., outpatient) was not provided. Then contact the FP’s office and suggest that when they use code 59430, they should add the modifier -52 and explain to the payer which part of the postpartum care (i.e., inpatient) was not performed. That way, both health-care providers should be reimbursed fairly.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Many patients in our practice see their family physician (FP) for prenatal care. Our obstetrician then performs the delivery and inpatient postpartum care, and the FP handles the outpatient postpartum care in the clinic. The dilemma arises when a cesarean delivery is performed and the FP’s office bills 59430, a postpartum care-only code that includes both inpatient and outpatient care. How should the Ob bill for his services?

A Unfortunately, the cesarean delivery-only codes (59514 and 59620 for failed VBAC) do not include any postpartum care, and the cesarean delivery plus postpartum care codes (59515 and 59622) include both inpatient and outpatient postpartum care, per the ACOG Coding Manual. However, in the case you described, you need to communicate to the payer that the postpartum care was divided between the obstetrician and the FP. Otherwise, some payers might deny the service billed by the FP or inquire why the Ob billed for a service not provided.

One way to avoid this dilemma: Bill for the cesarean delivery plus the postpartum care using the code 59515 or 59622 and add the modifier -52; be sure to carefully document which part of the service (i.e., outpatient) was not provided. Then contact the FP’s office and suggest that when they use code 59430, they should add the modifier -52 and explain to the payer which part of the postpartum care (i.e., inpatient) was not performed. That way, both health-care providers should be reimbursed fairly.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Many patients in our practice see their family physician (FP) for prenatal care. Our obstetrician then performs the delivery and inpatient postpartum care, and the FP handles the outpatient postpartum care in the clinic. The dilemma arises when a cesarean delivery is performed and the FP’s office bills 59430, a postpartum care-only code that includes both inpatient and outpatient care. How should the Ob bill for his services?

A Unfortunately, the cesarean delivery-only codes (59514 and 59620 for failed VBAC) do not include any postpartum care, and the cesarean delivery plus postpartum care codes (59515 and 59622) include both inpatient and outpatient postpartum care, per the ACOG Coding Manual. However, in the case you described, you need to communicate to the payer that the postpartum care was divided between the obstetrician and the FP. Otherwise, some payers might deny the service billed by the FP or inquire why the Ob billed for a service not provided.

One way to avoid this dilemma: Bill for the cesarean delivery plus the postpartum care using the code 59515 or 59622 and add the modifier -52; be sure to carefully document which part of the service (i.e., outpatient) was not provided. Then contact the FP’s office and suggest that when they use code 59430, they should add the modifier -52 and explain to the payer which part of the postpartum care (i.e., inpatient) was not performed. That way, both health-care providers should be reimbursed fairly.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Our patient had tandems and ovoids (T&O) inserted by the same physician on April 30 and then again on May 7. Our claim-manager software indicated that we could not bill for both procedures because of the global period. Should we use the modifier -76 (repeat procedure by the same physician) to bill for the second T&O?

A You actually have 2 options in this case. The modifier -58 would be the modifier of choice if the second T&O insertion was planned at the time of the first insertion, i.e., a staged procedure. On the other hand, if the physician decided on a second insertion at some point after the first insertion, the modifier -76 would be the better code.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Our patient had tandems and ovoids (T&O) inserted by the same physician on April 30 and then again on May 7. Our claim-manager software indicated that we could not bill for both procedures because of the global period. Should we use the modifier -76 (repeat procedure by the same physician) to bill for the second T&O?

A You actually have 2 options in this case. The modifier -58 would be the modifier of choice if the second T&O insertion was planned at the time of the first insertion, i.e., a staged procedure. On the other hand, if the physician decided on a second insertion at some point after the first insertion, the modifier -76 would be the better code.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Our patient had tandems and ovoids (T&O) inserted by the same physician on April 30 and then again on May 7. Our claim-manager software indicated that we could not bill for both procedures because of the global period. Should we use the modifier -76 (repeat procedure by the same physician) to bill for the second T&O?

A You actually have 2 options in this case. The modifier -58 would be the modifier of choice if the second T&O insertion was planned at the time of the first insertion, i.e., a staged procedure. On the other hand, if the physician decided on a second insertion at some point after the first insertion, the modifier -76 would be the better code.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 A gravida presented to the labor and delivery (L&D) unit of the hospital with symptoms indicative of preterm labor. A physician examined the patient and counseled her without admitting her. Is this considered an “office visit” under the global obstetric code and, therefore, counted toward the 13 antepartum visits, or is it considered a separate E/M visit that should be billed on the date of service?

A Since the physician performed an out-patient service (because the gravida was not admitted to the hospital or for observation care), most payers may consider the visit as a part of the global care, even though the service was performed in the hospital, not in an office.

Nonetheless, bill this encounter as a separate E/M visit on the date of service. The reasons: Your claim will clearly show that the place of service was not the office, and the diagnosis code will be the patient’s presenting symptoms. This may help you obtain reimbursement outside of the global fee.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 A gravida presented to the labor and delivery (L&D) unit of the hospital with symptoms indicative of preterm labor. A physician examined the patient and counseled her without admitting her. Is this considered an “office visit” under the global obstetric code and, therefore, counted toward the 13 antepartum visits, or is it considered a separate E/M visit that should be billed on the date of service?

A Since the physician performed an out-patient service (because the gravida was not admitted to the hospital or for observation care), most payers may consider the visit as a part of the global care, even though the service was performed in the hospital, not in an office.

Nonetheless, bill this encounter as a separate E/M visit on the date of service. The reasons: Your claim will clearly show that the place of service was not the office, and the diagnosis code will be the patient’s presenting symptoms. This may help you obtain reimbursement outside of the global fee.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 A gravida presented to the labor and delivery (L&D) unit of the hospital with symptoms indicative of preterm labor. A physician examined the patient and counseled her without admitting her. Is this considered an “office visit” under the global obstetric code and, therefore, counted toward the 13 antepartum visits, or is it considered a separate E/M visit that should be billed on the date of service?

A Since the physician performed an out-patient service (because the gravida was not admitted to the hospital or for observation care), most payers may consider the visit as a part of the global care, even though the service was performed in the hospital, not in an office.

Nonetheless, bill this encounter as a separate E/M visit on the date of service. The reasons: Your claim will clearly show that the place of service was not the office, and the diagnosis code will be the patient’s presenting symptoms. This may help you obtain reimbursement outside of the global fee.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Please explain what “by the same physician” means in the CPT definition of modifiers -24, -58, -76, and -79. Does it mean literally the same physician or can it mean within the same group practice and specialty, i.e., same tax ID number?

A Simply put, it means “the physician who performed the last procedure that initiated the global period.” What makes the situation more complex is how insurance companies process claims for physicians within a group practice and how they treat covering physicians during the global period. The question then becomes: How will my insurance company view the use of these modifiers for payment purposes? For instance, the modifier -24 means that the physician who performed the original surgical procedure is now seeing the patient for an unrelated problem (E/M service) during the global period. If all physicians in a single-specialty practice are considered the “same physician” for billing purposes, use this modifier to bypass the global period restrictions for postoperative care.

The same logic might apply to the other modifiers. For example, the modifier -58 means that the surgeon who performed the first surgical procedure is now doing a staged or related procedure during the global period of the first procedure; the modifier -76 signals that the surgeon who performed the first surgical procedure is repeating that procedure for a second time; and the modifier -79 indicates that the original surgeon is performing an unrelated procedure or service during the global period.

These modifiers also apply to “covering” physicians because, in most cases, this doctor is considered the same as the patient’s regular physician for billing purposes. The bottom line: The covering physician can bill for the same services and procedures as the regular clinician during the global period. The modifiers simply define the circumstances.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Please explain what “by the same physician” means in the CPT definition of modifiers -24, -58, -76, and -79. Does it mean literally the same physician or can it mean within the same group practice and specialty, i.e., same tax ID number?

A Simply put, it means “the physician who performed the last procedure that initiated the global period.” What makes the situation more complex is how insurance companies process claims for physicians within a group practice and how they treat covering physicians during the global period. The question then becomes: How will my insurance company view the use of these modifiers for payment purposes? For instance, the modifier -24 means that the physician who performed the original surgical procedure is now seeing the patient for an unrelated problem (E/M service) during the global period. If all physicians in a single-specialty practice are considered the “same physician” for billing purposes, use this modifier to bypass the global period restrictions for postoperative care.

The same logic might apply to the other modifiers. For example, the modifier -58 means that the surgeon who performed the first surgical procedure is now doing a staged or related procedure during the global period of the first procedure; the modifier -76 signals that the surgeon who performed the first surgical procedure is repeating that procedure for a second time; and the modifier -79 indicates that the original surgeon is performing an unrelated procedure or service during the global period.

These modifiers also apply to “covering” physicians because, in most cases, this doctor is considered the same as the patient’s regular physician for billing purposes. The bottom line: The covering physician can bill for the same services and procedures as the regular clinician during the global period. The modifiers simply define the circumstances.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 Please explain what “by the same physician” means in the CPT definition of modifiers -24, -58, -76, and -79. Does it mean literally the same physician or can it mean within the same group practice and specialty, i.e., same tax ID number?

A Simply put, it means “the physician who performed the last procedure that initiated the global period.” What makes the situation more complex is how insurance companies process claims for physicians within a group practice and how they treat covering physicians during the global period. The question then becomes: How will my insurance company view the use of these modifiers for payment purposes? For instance, the modifier -24 means that the physician who performed the original surgical procedure is now seeing the patient for an unrelated problem (E/M service) during the global period. If all physicians in a single-specialty practice are considered the “same physician” for billing purposes, use this modifier to bypass the global period restrictions for postoperative care.

The same logic might apply to the other modifiers. For example, the modifier -58 means that the surgeon who performed the first surgical procedure is now doing a staged or related procedure during the global period of the first procedure; the modifier -76 signals that the surgeon who performed the first surgical procedure is repeating that procedure for a second time; and the modifier -79 indicates that the original surgeon is performing an unrelated procedure or service during the global period.

These modifiers also apply to “covering” physicians because, in most cases, this doctor is considered the same as the patient’s regular physician for billing purposes. The bottom line: The covering physician can bill for the same services and procedures as the regular clinician during the global period. The modifiers simply define the circumstances.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 One of our physicians attempted a hysteroscopic dilatation and curettage (D&C), but several attempts at cervical dilation were unsuccessful. The physician abandoned the procedure and proceeded with a traditional D&C. Should we use the code 58558 with the modifier-53, plus the code 58120?

A There are 2 problems with your suggested coding. First, the code 58120 (D&C) is included in the code 58558 (hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) and would likely be denied by the payer as a bundled service. Second, the modifier-53 is used only when a procedure is completely stopped due to the patient’s condition, e.g., fall in blood pressure, and she is sent home or to the recovery room.

In this case, you abandoned the first procedure and began and completed a second procedure. If this were a Medicare patient, you would be allowed to bill only for the second procedure. Other payers may allow you to also bill for the “failed” procedure, especially if your documentation shows significant work. To do this, you might want to bill for the traditional D&C (58120) and add the modifier-22. As always, be sure to send documentation with the claim.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 our physicians attempted a hysteroscopic dilatation and curettage (D&C), but several attempts at cervical dilation were unsuccessful. The physician abandoned the procedure and proceeded with a traditional D&C. Should we use the code 58558 with the modifier-53, plus the code 58120?

A There are 2 problems with your suggested coding. First, the code 58120 (D&C) is included in the code 58558 (hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) and would likely be denied by the payer as a bundled service. Second, the modifier-53 is used only when a procedure is completely stopped due to the patient’s condition, e.g., fall in blood pressure, and she is sent home or to the recovery room.

In this case, you abandoned the first procedure and began and completed a second procedure. If this were a Medicare patient, you would be allowed to bill only for the second procedure. Other payers may allow you to also bill for the “failed” procedure, especially if your documentation shows significant work. To do this, you might want to bill for the traditional D&C (58120) and add the modifier-22. As always, be sure to send documentation with the claim.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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 our physicians attempted a hysteroscopic dilatation and curettage (D&C), but several attempts at cervical dilation were unsuccessful. The physician abandoned the procedure and proceeded with a traditional D&C. Should we use the code 58558 with the modifier-53, plus the code 58120?

A There are 2 problems with your suggested coding. First, the code 58120 (D&C) is included in the code 58558 (hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) and would likely be denied by the payer as a bundled service. Second, the modifier-53 is used only when a procedure is completely stopped due to the patient’s condition, e.g., fall in blood pressure, and she is sent home or to the recovery room.

In this case, you abandoned the first procedure and began and completed a second procedure. If this were a Medicare patient, you would be allowed to bill only for the second procedure. Other payers may allow you to also bill for the “failed” procedure, especially if your documentation shows significant work. To do this, you might want to bill for the traditional D&C (58120) and add the modifier-22. As always, be sure to send documentation with the claim.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a physician spends more than 50% of an in-office visit counseling and/or coordinating care, we select the appropriate E/M services code based on the amount of time spent counseling, not the total-visit time. How are the 2 different? And does the latter include only physician/patient interactions or can it include the time spent with nurses, medical assistants, etc.?

A Think of the criteria for selecting an E/M code based on time as consisting of 2 factors. First, the counseling time must represent more than 50% of the face-to-face time. Second, if the first condition is met, select the code based on the total face-to-face time documented in the patient’s medical record. This total-visit time is reflected in the nomenclature of each E/M code as follows: “physicians typically spend XX minutes face-to-face with the patient and/or family.”

When documenting the amount of time, record both the total time spent face-to-face with the patient and the amount of time spent counseling the patient. If you only did counseling, i.e., no exam, indicate this in the documentation and record only the face-to-face counseling time. For example, if the total-visit time was 25 minutes and the physician documented that 15 minutes was spent counseling (which meets the 50% requirement), the E/M code would be based on the 25 minutes (99214 for an established patient or 99202 for a new patient visit).

With regard to your second question, according to the CPT guidelines, the counseling time and total-visit time apply only to physician/patient interactions. Time spent with the patient by an RN, LPN, or medical assistant does not count toward this physician/patient time; therefore, it cannot be used to increase the total time of the visit. Note, however, that some payers will allow “counseling time” to be billed by a nonphysician practitioner, if this person provided the entire service. (Note: In these cases, payers usually require that the non-physician practitioner be a nurse practitioner, certified nurse-midwife, physician’s assistant, or certified nurse specialist.)

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a physician spends more than 50% of an in-office visit counseling and/or coordinating care, we select the appropriate E/M services code based on the amount of time spent counseling, not the total-visit time. How are the 2 different? And does the latter include only physician/patient interactions or can it include the time spent with nurses, medical assistants, etc.?

A Think of the criteria for selecting an E/M code based on time as consisting of 2 factors. First, the counseling time must represent more than 50% of the face-to-face time. Second, if the first condition is met, select the code based on the total face-to-face time documented in the patient’s medical record. This total-visit time is reflected in the nomenclature of each E/M code as follows: “physicians typically spend XX minutes face-to-face with the patient and/or family.”

When documenting the amount of time, record both the total time spent face-to-face with the patient and the amount of time spent counseling the patient. If you only did counseling, i.e., no exam, indicate this in the documentation and record only the face-to-face counseling time. For example, if the total-visit time was 25 minutes and the physician documented that 15 minutes was spent counseling (which meets the 50% requirement), the E/M code would be based on the 25 minutes (99214 for an established patient or 99202 for a new patient visit).

With regard to your second question, according to the CPT guidelines, the counseling time and total-visit time apply only to physician/patient interactions. Time spent with the patient by an RN, LPN, or medical assistant does not count toward this physician/patient time; therefore, it cannot be used to increase the total time of the visit. Note, however, that some payers will allow “counseling time” to be billed by a nonphysician practitioner, if this person provided the entire service. (Note: In these cases, payers usually require that the non-physician practitioner be a nurse practitioner, certified nurse-midwife, physician’s assistant, or certified nurse specialist.)

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a physician spends more than 50% of an in-office visit counseling and/or coordinating care, we select the appropriate E/M services code based on the amount of time spent counseling, not the total-visit time. How are the 2 different? And does the latter include only physician/patient interactions or can it include the time spent with nurses, medical assistants, etc.?

A Think of the criteria for selecting an E/M code based on time as consisting of 2 factors. First, the counseling time must represent more than 50% of the face-to-face time. Second, if the first condition is met, select the code based on the total face-to-face time documented in the patient’s medical record. This total-visit time is reflected in the nomenclature of each E/M code as follows: “physicians typically spend XX minutes face-to-face with the patient and/or family.”

When documenting the amount of time, record both the total time spent face-to-face with the patient and the amount of time spent counseling the patient. If you only did counseling, i.e., no exam, indicate this in the documentation and record only the face-to-face counseling time. For example, if the total-visit time was 25 minutes and the physician documented that 15 minutes was spent counseling (which meets the 50% requirement), the E/M code would be based on the 25 minutes (99214 for an established patient or 99202 for a new patient visit).

With regard to your second question, according to the CPT guidelines, the counseling time and total-visit time apply only to physician/patient interactions. Time spent with the patient by an RN, LPN, or medical assistant does not count toward this physician/patient time; therefore, it cannot be used to increase the total time of the visit. Note, however, that some payers will allow “counseling time” to be billed by a nonphysician practitioner, if this person provided the entire service. (Note: In these cases, payers usually require that the non-physician practitioner be a nurse practitioner, certified nurse-midwife, physician’s assistant, or certified nurse specialist.)

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect 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.