Reimbursement Advisor

Additions and revision to this year’s International Classification of Diseases, Clinical Modification (ICD-9-CM)—which go into effect on October 1—reflect tinkering with existing codes and expansion of others to boost granularity and clarity in your reporting of diagnostic work. To that add a number of new codes—including one that acknowledges the arrival of the H1N1 (swine flu) virus nationwide.

In obstetrics, there are now specific codes for different types of puerperal infection and a requirement for more diagnostic information when a patient has venous complications during pregnancy and intrapartum.

On the gynecology side, changes include the way you report a finding of endometrial intraepithelial neoplasia. New codes have been created to report:

• visits and procedures for fertility preservation
  
• inconclusive mammography
  
• preprocedural laboratory testing.
  

Remember: On October 1, 2009, the new and revised codes discussed here, plus others, will be added to the national ICD-9-CM code set. Be cautioned that, as in past years, there is no grace period!

Changes to obstetric codes

PUERPERAL INFECTIONS

Before October 1, 2009, all puerperal infections were lumped into one code: 670.0 (Major puerperal infection). This changes now: You’ll be required to document, more specifically, the type of infection that your patient has.

Continue to report code 670.0 for an unspecified puerperal infection; but, if you admit the patient to the hospital, using that unspecified code may lead to a first-submission denial of claim. A fifth digit is also required for the unspecified and new more specific codes: 0 (unspecified as to episode of care or not applicable), 2 (delivered with mention of postpartum complication), or 4 (postpartum condition or complication) (to be reported only once the patient is discharged after delivery).

670.1x [0,2,4]  Puerperal endometritis

670.2x [0,2,4]  Puerperal sepsis

670.3x [0,2,4]  Puerperal septic thrombophlebitis

670.8x [0,2,4]  Other major puerperal infection

VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM

Code category 671 (venous complications in pregnancy and the puerperium) retains its current codes, but ICD-9 has added notes to clarify that additional information is required.

For example: When a patient has deep-vein thrombosis, either antepartum (671.3x) or postpartum (671.4x), assign a secondary diagnosis from code category 453 (Other venous embolism and thrombosis). If, in addition, the patient has been taking an anticoagulant for a long time and is currently taking it, report code V56.81, as well, to indicate this.

Gyn code changes

HYPERPLASIA

Over time, codes for hyperplasia have evolved from a system that described mild, moderate, severe, or atypical, to one in which hyperplasia was subdivided by architectural complexity, such as simple versus complex and whether or not atypia were present. Even this terminology fails, however, to adequately identify patients’ risk of cancer to improve therapeutic triaging.

In more recent years, physicians and pathologists have begun to distinguish benign hormonal effects of unopposed estrogen, classified as benign hyperplasia, from pre-cancerous lesions classified as endometrial intraepithelial neoplasia (EIN). To capture this newer terminology, ICD-9 has added two new codes.

ICD-9 has elected to retain existing codes in this area of diagnosis and assessment because the old terminology is still used by many older practicing physicians. The hope, however, is that, over time, more accurate distinctions between the types of hyperplasia will replace the older distinctions.

A note in ICD-9 will instruct providers that older codes may not be reported if one of the newer codes is assigned.

An additional note that accompanies the EIN diagnosis indicates that, if a patient is given a diagnosis of malignant neoplasm of the endometrium with endometrial intraepithelial neoplasia, the code for the malignancy (182.0, Malignant neoplasm of body of uterus; corpus uteri, except isthmus) would be reported instead of the EIN code.

621.34  Benign endometrial hyperplasia

621.35  Endometrial intraepithelial neoplasia

INCONCLUSIVE MAMMOGRAM

Routine mammograms are, as you know, sometimes labeled “inconclusive” because of what are termed “dense breasts.” This finding isn’t considered to represent an abnormal condition, but it does require further testing to confirm that no malignant condition exists that cannot be seen on mammogram.

Because many payers cover a repeat mammogram only when an abnormal finding is reported, a new code has been needed—and has now been added—to explain the reason for a second mammogram.

Because of the added code, ICD-9 also decided to revise wording for the 793 code category (until now, it’s been Nonspecific abnormal findings on radiological and other examination of body structure) to a more general heading of Nonspecific findings, which covers inconclusive and abnormal findings.

793.82  Inconclusive mammogram

FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY

Two new codes have been added to this area of practice at the request of the American Society for Reproductive Medicine (ASRM) and ACOG. They allow you to report visits and procedures aimed at preserving fertility in women who must undergo chemotherapy, surgery, or radiation therapy that might otherwise leave them sterile.

The codes reflect that, before a patient is treated, you may discuss a range of options that can increase her chances of becoming pregnant, including:

• conception before cancer treatment
  
• banking of sperm, eggs, ovarian tissue, and embryos
  
• protecting the ovaries during radiation therapy
  
• modifying surgery to spare the uterus.
  

V26.42  Encounter for fertility preservation counseling

V26.82  Encounter for fertility preservation procedure

PREPROCEDURAL EVALUATIONS

Code category V72.6 has been expanded from four to five digits to better capture reasons for ordering or performing laboratory tests that are not specifically linked to a medical diagnosis.

For example: If you order routine tests as part of a routine, general medical or gyn annual examination, report code V72.62. For routine preoperative lab tests, report V72.63 instead.

ICD-9 has clarified that V72.61 can be reported for testing of immune status, and that current code V72.83 (Other specified pre-operative examination) is the one to report when an exam precedes chemotherapy.

Note: ICD-9 rules require that you list the preprocedural examination code as the primary diagnosis, followed by the code that represents the reason for the surgery or procedure.

V72.60  Laboratory examination, unspecified

V72.61  Antibody response examination

V72.62  Laboratory examination ordered as part of a routine general medical examination

V72.63  Preprocedural laboratory examination

V72.69  Other laboratory examination

PERSONAL HISTORY CODES

A history of drug therapy can affect the care that you are giving a patient now, and may require testing from time to time to assess the consequences of such therapy.

Two examples are long-term estrogen therapy, which may increase a woman’s risk of developing breast cancer, and inhaled steroids, which can decrease bone density. In the absence of a known problem with these (or other) therapies in a given patient, new history codes listed below may be useful in communicating with a payer about ongoing follow-up care or testing that you are providing.

V87.43  Personal history of estrogen therapy

V87.44  Personal history of inhaled steroid therapy

V87.45  Personal history of systemic steroid therapy

V87.46  Personal history of immunosuppressive therapy

Plus a number of miscellaneous additions and changes

Here are few more new codes that may better explain why you saw a patient, provided:

• the new code for swine flu is reported only for a confirmed case, per ICD-9 rules
  
• the new V codes are reported only if the personal history or family circumstance affected treatment at the time of the visit, or if the patient was receiving counseling concerning only those issues.
  

995.24  Failed moderate sedation during procedure

V10.90  Personal history of unspecified type of malignant neoplasm

V15.80  Personal history of failed moderate sedation

V61.07  Family disruption due to death of family member

V61.08  Family disruption due to other extended absence of a family member

V61.42  Substance abuse in family

Additions and revision to this year’s International Classification of Diseases, Clinical Modification (ICD-9-CM)—which go into effect on October 1—reflect tinkering with existing codes and expansion of others to boost granularity and clarity in your reporting of diagnostic work. To that add a number of new codes—including one that acknowledges the arrival of the H1N1 (swine flu) virus nationwide.

In obstetrics, there are now specific codes for different types of puerperal infection and a requirement for more diagnostic information when a patient has venous complications during pregnancy and intrapartum.

On the gynecology side, changes include the way you report a finding of endometrial intraepithelial neoplasia. New codes have been created to report:

• visits and procedures for fertility preservation
  
• inconclusive mammography
  
• preprocedural laboratory testing.
  

Remember: On October 1, 2009, the new and revised codes discussed here, plus others, will be added to the national ICD-9-CM code set. Be cautioned that, as in past years, there is no grace period!

Changes to obstetric codes

PUERPERAL INFECTIONS

Before October 1, 2009, all puerperal infections were lumped into one code: 670.0 (Major puerperal infection). This changes now: You’ll be required to document, more specifically, the type of infection that your patient has.

Continue to report code 670.0 for an unspecified puerperal infection; but, if you admit the patient to the hospital, using that unspecified code may lead to a first-submission denial of claim. A fifth digit is also required for the unspecified and new more specific codes: 0 (unspecified as to episode of care or not applicable), 2 (delivered with mention of postpartum complication), or 4 (postpartum condition or complication) (to be reported only once the patient is discharged after delivery).

670.1x [0,2,4]  Puerperal endometritis

670.2x [0,2,4]  Puerperal sepsis

670.3x [0,2,4]  Puerperal septic thrombophlebitis

670.8x [0,2,4]  Other major puerperal infection

VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM

Code category 671 (venous complications in pregnancy and the puerperium) retains its current codes, but ICD-9 has added notes to clarify that additional information is required.

For example: When a patient has deep-vein thrombosis, either antepartum (671.3x) or postpartum (671.4x), assign a secondary diagnosis from code category 453 (Other venous embolism and thrombosis). If, in addition, the patient has been taking an anticoagulant for a long time and is currently taking it, report code V56.81, as well, to indicate this.

Gyn code changes

HYPERPLASIA

Over time, codes for hyperplasia have evolved from a system that described mild, moderate, severe, or atypical, to one in which hyperplasia was subdivided by architectural complexity, such as simple versus complex and whether or not atypia were present. Even this terminology fails, however, to adequately identify patients’ risk of cancer to improve therapeutic triaging.

In more recent years, physicians and pathologists have begun to distinguish benign hormonal effects of unopposed estrogen, classified as benign hyperplasia, from pre-cancerous lesions classified as endometrial intraepithelial neoplasia (EIN). To capture this newer terminology, ICD-9 has added two new codes.

ICD-9 has elected to retain existing codes in this area of diagnosis and assessment because the old terminology is still used by many older practicing physicians. The hope, however, is that, over time, more accurate distinctions between the types of hyperplasia will replace the older distinctions.

A note in ICD-9 will instruct providers that older codes may not be reported if one of the newer codes is assigned.

An additional note that accompanies the EIN diagnosis indicates that, if a patient is given a diagnosis of malignant neoplasm of the endometrium with endometrial intraepithelial neoplasia, the code for the malignancy (182.0, Malignant neoplasm of body of uterus; corpus uteri, except isthmus) would be reported instead of the EIN code.

621.34  Benign endometrial hyperplasia

621.35  Endometrial intraepithelial neoplasia

INCONCLUSIVE MAMMOGRAM

Routine mammograms are, as you know, sometimes labeled “inconclusive” because of what are termed “dense breasts.” This finding isn’t considered to represent an abnormal condition, but it does require further testing to confirm that no malignant condition exists that cannot be seen on mammogram.

Because many payers cover a repeat mammogram only when an abnormal finding is reported, a new code has been needed—and has now been added—to explain the reason for a second mammogram.

Because of the added code, ICD-9 also decided to revise wording for the 793 code category (until now, it’s been Nonspecific abnormal findings on radiological and other examination of body structure) to a more general heading of Nonspecific findings, which covers inconclusive and abnormal findings.

793.82  Inconclusive mammogram

FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY

Two new codes have been added to this area of practice at the request of the American Society for Reproductive Medicine (ASRM) and ACOG. They allow you to report visits and procedures aimed at preserving fertility in women who must undergo chemotherapy, surgery, or radiation therapy that might otherwise leave them sterile.

The codes reflect that, before a patient is treated, you may discuss a range of options that can increase her chances of becoming pregnant, including:

• conception before cancer treatment
  
• banking of sperm, eggs, ovarian tissue, and embryos
  
• protecting the ovaries during radiation therapy
  
• modifying surgery to spare the uterus.
  

V26.42  Encounter for fertility preservation counseling

V26.82  Encounter for fertility preservation procedure

PREPROCEDURAL EVALUATIONS

Code category V72.6 has been expanded from four to five digits to better capture reasons for ordering or performing laboratory tests that are not specifically linked to a medical diagnosis.

For example: If you order routine tests as part of a routine, general medical or gyn annual examination, report code V72.62. For routine preoperative lab tests, report V72.63 instead.

ICD-9 has clarified that V72.61 can be reported for testing of immune status, and that current code V72.83 (Other specified pre-operative examination) is the one to report when an exam precedes chemotherapy.

Note: ICD-9 rules require that you list the preprocedural examination code as the primary diagnosis, followed by the code that represents the reason for the surgery or procedure.

V72.60  Laboratory examination, unspecified

V72.61  Antibody response examination

V72.62  Laboratory examination ordered as part of a routine general medical examination

V72.63  Preprocedural laboratory examination

V72.69  Other laboratory examination

PERSONAL HISTORY CODES

A history of drug therapy can affect the care that you are giving a patient now, and may require testing from time to time to assess the consequences of such therapy.

Two examples are long-term estrogen therapy, which may increase a woman’s risk of developing breast cancer, and inhaled steroids, which can decrease bone density. In the absence of a known problem with these (or other) therapies in a given patient, new history codes listed below may be useful in communicating with a payer about ongoing follow-up care or testing that you are providing.

V87.43  Personal history of estrogen therapy

V87.44  Personal history of inhaled steroid therapy

V87.45  Personal history of systemic steroid therapy

V87.46  Personal history of immunosuppressive therapy

Plus a number of miscellaneous additions and changes

Here are few more new codes that may better explain why you saw a patient, provided:

• the new code for swine flu is reported only for a confirmed case, per ICD-9 rules
  
• the new V codes are reported only if the personal history or family circumstance affected treatment at the time of the visit, or if the patient was receiving counseling concerning only those issues.
  

995.24  Failed moderate sedation during procedure

V10.90  Personal history of unspecified type of malignant neoplasm

V15.80  Personal history of failed moderate sedation

V61.07  Family disruption due to death of family member

V61.08  Family disruption due to other extended absence of a family member

V61.42  Substance abuse in family

Additions and revision to this year’s International Classification of Diseases, Clinical Modification (ICD-9-CM)—which go into effect on October 1—reflect tinkering with existing codes and expansion of others to boost granularity and clarity in your reporting of diagnostic work. To that add a number of new codes—including one that acknowledges the arrival of the H1N1 (swine flu) virus nationwide.

In obstetrics, there are now specific codes for different types of puerperal infection and a requirement for more diagnostic information when a patient has venous complications during pregnancy and intrapartum.

On the gynecology side, changes include the way you report a finding of endometrial intraepithelial neoplasia. New codes have been created to report:

• visits and procedures for fertility preservation
  
• inconclusive mammography
  
• preprocedural laboratory testing.
  

Remember: On October 1, 2009, the new and revised codes discussed here, plus others, will be added to the national ICD-9-CM code set. Be cautioned that, as in past years, there is no grace period!

Changes to obstetric codes

PUERPERAL INFECTIONS

Before October 1, 2009, all puerperal infections were lumped into one code: 670.0 (Major puerperal infection). This changes now: You’ll be required to document, more specifically, the type of infection that your patient has.

Continue to report code 670.0 for an unspecified puerperal infection; but, if you admit the patient to the hospital, using that unspecified code may lead to a first-submission denial of claim. A fifth digit is also required for the unspecified and new more specific codes: 0 (unspecified as to episode of care or not applicable), 2 (delivered with mention of postpartum complication), or 4 (postpartum condition or complication) (to be reported only once the patient is discharged after delivery).

670.1x [0,2,4]  Puerperal endometritis

670.2x [0,2,4]  Puerperal sepsis

670.3x [0,2,4]  Puerperal septic thrombophlebitis

670.8x [0,2,4]  Other major puerperal infection

VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM

Code category 671 (venous complications in pregnancy and the puerperium) retains its current codes, but ICD-9 has added notes to clarify that additional information is required.

For example: When a patient has deep-vein thrombosis, either antepartum (671.3x) or postpartum (671.4x), assign a secondary diagnosis from code category 453 (Other venous embolism and thrombosis). If, in addition, the patient has been taking an anticoagulant for a long time and is currently taking it, report code V56.81, as well, to indicate this.

Gyn code changes

HYPERPLASIA

Over time, codes for hyperplasia have evolved from a system that described mild, moderate, severe, or atypical, to one in which hyperplasia was subdivided by architectural complexity, such as simple versus complex and whether or not atypia were present. Even this terminology fails, however, to adequately identify patients’ risk of cancer to improve therapeutic triaging.

In more recent years, physicians and pathologists have begun to distinguish benign hormonal effects of unopposed estrogen, classified as benign hyperplasia, from pre-cancerous lesions classified as endometrial intraepithelial neoplasia (EIN). To capture this newer terminology, ICD-9 has added two new codes.

ICD-9 has elected to retain existing codes in this area of diagnosis and assessment because the old terminology is still used by many older practicing physicians. The hope, however, is that, over time, more accurate distinctions between the types of hyperplasia will replace the older distinctions.

A note in ICD-9 will instruct providers that older codes may not be reported if one of the newer codes is assigned.

An additional note that accompanies the EIN diagnosis indicates that, if a patient is given a diagnosis of malignant neoplasm of the endometrium with endometrial intraepithelial neoplasia, the code for the malignancy (182.0, Malignant neoplasm of body of uterus; corpus uteri, except isthmus) would be reported instead of the EIN code.

621.34  Benign endometrial hyperplasia

621.35  Endometrial intraepithelial neoplasia

INCONCLUSIVE MAMMOGRAM

Routine mammograms are, as you know, sometimes labeled “inconclusive” because of what are termed “dense breasts.” This finding isn’t considered to represent an abnormal condition, but it does require further testing to confirm that no malignant condition exists that cannot be seen on mammogram.

Because many payers cover a repeat mammogram only when an abnormal finding is reported, a new code has been needed—and has now been added—to explain the reason for a second mammogram.

Because of the added code, ICD-9 also decided to revise wording for the 793 code category (until now, it’s been Nonspecific abnormal findings on radiological and other examination of body structure) to a more general heading of Nonspecific findings, which covers inconclusive and abnormal findings.

793.82  Inconclusive mammogram

FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY

Two new codes have been added to this area of practice at the request of the American Society for Reproductive Medicine (ASRM) and ACOG. They allow you to report visits and procedures aimed at preserving fertility in women who must undergo chemotherapy, surgery, or radiation therapy that might otherwise leave them sterile.

The codes reflect that, before a patient is treated, you may discuss a range of options that can increase her chances of becoming pregnant, including:

• conception before cancer treatment
  
• banking of sperm, eggs, ovarian tissue, and embryos
  
• protecting the ovaries during radiation therapy
  
• modifying surgery to spare the uterus.
  

V26.42  Encounter for fertility preservation counseling

V26.82  Encounter for fertility preservation procedure

PREPROCEDURAL EVALUATIONS

Code category V72.6 has been expanded from four to five digits to better capture reasons for ordering or performing laboratory tests that are not specifically linked to a medical diagnosis.

For example: If you order routine tests as part of a routine, general medical or gyn annual examination, report code V72.62. For routine preoperative lab tests, report V72.63 instead.

ICD-9 has clarified that V72.61 can be reported for testing of immune status, and that current code V72.83 (Other specified pre-operative examination) is the one to report when an exam precedes chemotherapy.

Note: ICD-9 rules require that you list the preprocedural examination code as the primary diagnosis, followed by the code that represents the reason for the surgery or procedure.

V72.60  Laboratory examination, unspecified

V72.61  Antibody response examination

V72.62  Laboratory examination ordered as part of a routine general medical examination

V72.63  Preprocedural laboratory examination

V72.69  Other laboratory examination

PERSONAL HISTORY CODES

A history of drug therapy can affect the care that you are giving a patient now, and may require testing from time to time to assess the consequences of such therapy.

Two examples are long-term estrogen therapy, which may increase a woman’s risk of developing breast cancer, and inhaled steroids, which can decrease bone density. In the absence of a known problem with these (or other) therapies in a given patient, new history codes listed below may be useful in communicating with a payer about ongoing follow-up care or testing that you are providing.

V87.43  Personal history of estrogen therapy

V87.44  Personal history of inhaled steroid therapy

V87.45  Personal history of systemic steroid therapy

V87.46  Personal history of immunosuppressive therapy

Plus a number of miscellaneous additions and changes

Here are few more new codes that may better explain why you saw a patient, provided:

• the new code for swine flu is reported only for a confirmed case, per ICD-9 rules
  
• the new V codes are reported only if the personal history or family circumstance affected treatment at the time of the visit, or if the patient was receiving counseling concerning only those issues.
  

995.24  Failed moderate sedation during procedure

V10.90  Personal history of unspecified type of malignant neoplasm

V15.80  Personal history of failed moderate sedation

V61.07  Family disruption due to death of family member

V61.08  Family disruption due to other extended absence of a family member

V61.42  Substance abuse in family

Routine screening for the human immunodeficiency virus (HIV) is recommended for all women 19 to 64 years old, according to guidelines issued in August 2008 by the American College of Obstetricians and Gynecologists (ACOG). In addition, ACOG recommends that women outside that age range who have a risk factor for HIV infection undergo targeted screening.

To accomplish these goals, ACOG suggests “opt-out” HIV screening, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care unless she declines it.

Opt-out testing may not always be feasible, however, because many payers still require that you counsel the patient about the HIV test before it is performed, as well as have her sign a consent form.

Information about individual states’ requirements for testing, counseling, and informed consent can be found at the Compendium of State HIV Testing Laws, Quick Reference Guide for Clinicians (March 17, 2009), prepared by the National HIV/AIDS Clinicians’ Consultation Center at www.nccc.ucsf.edu/StateLaws/About%20Compendium/Quick%20Reference%20Guide.pdf.

The patient may be offered the test during any of the following:

• her preventive health checkup
  
• an office visit for a presenting problem
  
• a scheduled obstetric visit.
  

When you provide counseling, bill for it!

Counseling for HIV in the absence of the condition is considered a preventive service, which is reported using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual), based on total counseling time between 15 and 60 minutes (reported in 15-minute increments). Such preventive counseling can be reported in addition to a problem E/M service by adding the modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the problem E/M code. It can also be reported separately at the time of an obstetric visit. However, such counseling is not covered when it is conducted during a preventive exam.

Include the proper diagnostic code

Diagnostic coding, following these ICD-9 rules, lets the payer know why the service is being rendered:

• Report V73.89 (Screening for other specified viral disease) if the patient is being seen to determine her HIV status.
  
• Report V69.8 (Other problems related to lifestyle) as a secondary diagnosis if the patient is in a group known to be at high risk of HIV infection.
  
• Report V65.44 (HIV counseling) for counseling provided during the encounter for the test, or use this code to report the visit at which the patient returns to discuss her result.
  

Just what constitutes “routine” testing?

The ACOG guidelines are unclear as to what, exactly, “routine” testing means. Is an ObGyn expected to test a patient once in her lifetime, annually, or any time her life partner changes?

These specifics are not addressed in the ACOG recommendations. Based on similar recommendations from the Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF), however, you might surmise the following:

• Test all patients 19 to 64 years old for HIV at least once.
  
• Test all patients at high risk of contracting HIV annually. (High-risk groups include women who receive a blood transfusion, practice unsafe sex, or have a new sexual partner who has not been tested.)
  
• Test all women each time they become pregnant.
  

• HIV screening be carried out after the patient is notified that testing will be performed, unless she declines (opt-out screening)
  
• any person who is at high risk of contracting HIV be screened at least annually
  
• separate written consent for HIV testing not be required (general consent for medical care should be sufficient to encompass consent for HIV testing)
  
• prevention counseling not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings
  
• among pregnant women, HIV screening be included in the routine panel of prenatal screening tests
  
• every pregnant woman be screened for HIV after she is notified that testing will be performed, unless she declines (opt-out screening)
  
• separate written consent for HIV testing not be required for pregnant women (general consent for medical care should be sufficient to encompass consent for HIV testing)
  
• repeat screening in the third trimester be carried out in certain jurisdictions that have an elevated rate of HIV infection among pregnant women.
  

Routine screening for the human immunodeficiency virus (HIV) is recommended for all women 19 to 64 years old, according to guidelines issued in August 2008 by the American College of Obstetricians and Gynecologists (ACOG). In addition, ACOG recommends that women outside that age range who have a risk factor for HIV infection undergo targeted screening.

To accomplish these goals, ACOG suggests “opt-out” HIV screening, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care unless she declines it.

Opt-out testing may not always be feasible, however, because many payers still require that you counsel the patient about the HIV test before it is performed, as well as have her sign a consent form.

Information about individual states’ requirements for testing, counseling, and informed consent can be found at the Compendium of State HIV Testing Laws, Quick Reference Guide for Clinicians (March 17, 2009), prepared by the National HIV/AIDS Clinicians’ Consultation Center at www.nccc.ucsf.edu/StateLaws/About%20Compendium/Quick%20Reference%20Guide.pdf.

The patient may be offered the test during any of the following:

• her preventive health checkup
  
• an office visit for a presenting problem
  
• a scheduled obstetric visit.
  

When you provide counseling, bill for it!

Counseling for HIV in the absence of the condition is considered a preventive service, which is reported using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual), based on total counseling time between 15 and 60 minutes (reported in 15-minute increments). Such preventive counseling can be reported in addition to a problem E/M service by adding the modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the problem E/M code. It can also be reported separately at the time of an obstetric visit. However, such counseling is not covered when it is conducted during a preventive exam.

Include the proper diagnostic code

Diagnostic coding, following these ICD-9 rules, lets the payer know why the service is being rendered:

• Report V73.89 (Screening for other specified viral disease) if the patient is being seen to determine her HIV status.
  
• Report V69.8 (Other problems related to lifestyle) as a secondary diagnosis if the patient is in a group known to be at high risk of HIV infection.
  
• Report V65.44 (HIV counseling) for counseling provided during the encounter for the test, or use this code to report the visit at which the patient returns to discuss her result.
  

Just what constitutes “routine” testing?

The ACOG guidelines are unclear as to what, exactly, “routine” testing means. Is an ObGyn expected to test a patient once in her lifetime, annually, or any time her life partner changes?

These specifics are not addressed in the ACOG recommendations. Based on similar recommendations from the Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF), however, you might surmise the following:

• Test all patients 19 to 64 years old for HIV at least once.
  
• Test all patients at high risk of contracting HIV annually. (High-risk groups include women who receive a blood transfusion, practice unsafe sex, or have a new sexual partner who has not been tested.)
  
• Test all women each time they become pregnant.
  

• HIV screening be carried out after the patient is notified that testing will be performed, unless she declines (opt-out screening)
  
• any person who is at high risk of contracting HIV be screened at least annually
  
• separate written consent for HIV testing not be required (general consent for medical care should be sufficient to encompass consent for HIV testing)
  
• prevention counseling not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings
  
• among pregnant women, HIV screening be included in the routine panel of prenatal screening tests
  
• every pregnant woman be screened for HIV after she is notified that testing will be performed, unless she declines (opt-out screening)
  
• separate written consent for HIV testing not be required for pregnant women (general consent for medical care should be sufficient to encompass consent for HIV testing)
  
• repeat screening in the third trimester be carried out in certain jurisdictions that have an elevated rate of HIV infection among pregnant women.
  

Routine screening for the human immunodeficiency virus (HIV) is recommended for all women 19 to 64 years old, according to guidelines issued in August 2008 by the American College of Obstetricians and Gynecologists (ACOG). In addition, ACOG recommends that women outside that age range who have a risk factor for HIV infection undergo targeted screening.

To accomplish these goals, ACOG suggests “opt-out” HIV screening, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care unless she declines it.

Opt-out testing may not always be feasible, however, because many payers still require that you counsel the patient about the HIV test before it is performed, as well as have her sign a consent form.

Information about individual states’ requirements for testing, counseling, and informed consent can be found at the Compendium of State HIV Testing Laws, Quick Reference Guide for Clinicians (March 17, 2009), prepared by the National HIV/AIDS Clinicians’ Consultation Center at www.nccc.ucsf.edu/StateLaws/About%20Compendium/Quick%20Reference%20Guide.pdf.

The patient may be offered the test during any of the following:

• her preventive health checkup
  
• an office visit for a presenting problem
  
• a scheduled obstetric visit.
  

When you provide counseling, bill for it!

Counseling for HIV in the absence of the condition is considered a preventive service, which is reported using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual), based on total counseling time between 15 and 60 minutes (reported in 15-minute increments). Such preventive counseling can be reported in addition to a problem E/M service by adding the modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the problem E/M code. It can also be reported separately at the time of an obstetric visit. However, such counseling is not covered when it is conducted during a preventive exam.

Include the proper diagnostic code

Diagnostic coding, following these ICD-9 rules, lets the payer know why the service is being rendered:

• Report V73.89 (Screening for other specified viral disease) if the patient is being seen to determine her HIV status.
  
• Report V69.8 (Other problems related to lifestyle) as a secondary diagnosis if the patient is in a group known to be at high risk of HIV infection.
  
• Report V65.44 (HIV counseling) for counseling provided during the encounter for the test, or use this code to report the visit at which the patient returns to discuss her result.
  

Just what constitutes “routine” testing?

The ACOG guidelines are unclear as to what, exactly, “routine” testing means. Is an ObGyn expected to test a patient once in her lifetime, annually, or any time her life partner changes?

These specifics are not addressed in the ACOG recommendations. Based on similar recommendations from the Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force (USPSTF), however, you might surmise the following:

• Test all patients 19 to 64 years old for HIV at least once.
  
• Test all patients at high risk of contracting HIV annually. (High-risk groups include women who receive a blood transfusion, practice unsafe sex, or have a new sexual partner who has not been tested.)
  
• Test all women each time they become pregnant.
  

• HIV screening be carried out after the patient is notified that testing will be performed, unless she declines (opt-out screening)
  
• any person who is at high risk of contracting HIV be screened at least annually
  
• separate written consent for HIV testing not be required (general consent for medical care should be sufficient to encompass consent for HIV testing)
  
• prevention counseling not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings
  
• among pregnant women, HIV screening be included in the routine panel of prenatal screening tests
  
• every pregnant woman be screened for HIV after she is notified that testing will be performed, unless she declines (opt-out screening)
  
• separate written consent for HIV testing not be required for pregnant women (general consent for medical care should be sufficient to encompass consent for HIV testing)
  
• repeat screening in the third trimester be carried out in certain jurisdictions that have an elevated rate of HIV infection among pregnant women.
  

Take note, ObGyns: A number of changes in Current Procedural Terminology (CPT) 2009—those changes took effect January 1—are going to modify the way you bill and will have an impact on your reimbursement. Most of these changes are minor, although renumbering of infusion codes will require changes to the encounter form. And I have good and bad news for urogynecologists who perform vaginal paravaginal repairs and sling procedures for stress urinary incontinence. Read on for details!

Mesh for vaginal paravaginal defect repair—
code error corrected

Code 57267 is an add-on code that describes the insertion of mesh, or other prosthesis, through a vaginal approach when native tissues have been determined to be weak and inadequate for repair—especially in patients who have undergone a previous attempt at repair. As an add-on code, it can be billed only in addition to other, specific procedures.

Before January 1, code 57267 could only be reported with an anterior or posterior colporrhaphy, or both, or with a rectocele repair without colporrhaphy.

When performing a vaginal approach paravaginal defect repair, however, the same weakened tissues also require use of the mesh, yet code 57825 (paravaginal defect repair [including repair of cystocele, if performed]) was not included as one of the allowed codes. This error is rectified in 2009.

You must still be aware that reporting the 57267 add-on code requires that you establish medical necessity for its use. Documentation of weakened, attenuated, or incompetent pubocervical tissue in the case of a paravaginal repair (International Classification of Diseases Clinical Modification [ICD-9-CM] code 618.81) or rectovaginal tissue for rectocele/enterocele repair (618.82) continues to be important when reporting the add-on mesh code.

A reminder about anesthesia

Until January 1, codes 57400 (dilation of vagina), 57410 (pelvic examination), and 57415 (removal of impacted vaginal foreign body) read “under anesthesia.” In a move to standardize terminology, these codes will be revised to add the wording “other than local.” The revision clarifies that 1) all surgical codes include administration of a local anesthetic and 2) codes designated with “under anesthesia” refer to regional blocks and general anesthesia.

New human papillomavirus vaccine, new code

A new code, 90650, has been added to report the newer bivalent human papillomavirus (HPV) vaccine, which contains an adjuvant formulation and is intended to protect against infection by high-risk HPV types 16 and 18. The existing HPV vaccine code, 90649, targets those high-risk types of HPV and two low-risk types (6 and 11).

Coverage recommendations for the new vaccine match those of the existing, quadrivalent vaccine, but not all payers are covering the HPV vaccine based on those recommendations. The new vaccine offers a less costly alternative for patients whose health-care insurance does not cover the vaccine or who are uninsured.

Wholesale reorganization of injection and infusion codes

Codes 90760–90779 (covering therapeutic, prophylactic, and diagnostic injections and infusions) are deleted in 2009 and renumbered, with the same descriptors, to 96360–96379. This was done to organize all infusions and injections together. The biggest change for you and every other ObGyn? You must revise the practice’s encounter form to reflect the requirement that intramuscular and subcutaneous injections are now coded 96372 instead of 90772.

Modifier -21 and prolonged E/M services

Now deleted is Modifier -21 (prolonged evaluation and management [E/M] service). This modifier represented acknowledgment that a continuous face-to-face E/M service could exceed the maximum time allowed by the highest level of E/M service for the type being billed.

In other words, before January 1, 2009, if a patient’s condition was such that you documented an established or new patient visit (99215 or 99205) but in fact spent more time with her than the 45 or 60 minutes that typically accompanies these codes, you added modifier -21 in the hope of receiving higher reimbursement. Now the modifier is deleted because there is already a mechanism in place to report such prolonged service.

Add-on codes 99354–99357 are used to report face-to-face outpatient and inpatient prolonged E/M services. Guidelines for these codes mandate cumulative time rather than continuous time, and using the add-on codes is contingent on the additional time spent being 30 or more minutes above the typical time allotted for the basic E/M service that you are billing.

Here’s a case that exemplifies how coding works in these circumstances:

CASE

You evaluate a patient for severe uterine bleeding, and report a level-4 visit (99214), which has a typical time of 25 minutes. At the same visit, you determine that endometrial biopsy is required, and you perform it during the visit. But the patient faints during the procedure—and you spend an additional 35 minutes (cumulative time) with her before you send her home.

Because the typical time of 25 minutes was exceeded by at least 30 minutes, you should report 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for office or other outpatient Evaluation and Management service]) in addition to 99214.

Guidelines for correct use of these codes are also being revised to emphasize that only outpatient prolonged services codes are intended to be used to report total duration of face-to-face time; on the other hand, inpatient codes are intended to report the total duration of the time spent (whether continuous or noncontinuous) by the physician on the unit actively involved in caring for the patient.

Take note, ObGyns: A number of changes in Current Procedural Terminology (CPT) 2009—those changes took effect January 1—are going to modify the way you bill and will have an impact on your reimbursement. Most of these changes are minor, although renumbering of infusion codes will require changes to the encounter form. And I have good and bad news for urogynecologists who perform vaginal paravaginal repairs and sling procedures for stress urinary incontinence. Read on for details!

Mesh for vaginal paravaginal defect repair—
code error corrected

Code 57267 is an add-on code that describes the insertion of mesh, or other prosthesis, through a vaginal approach when native tissues have been determined to be weak and inadequate for repair—especially in patients who have undergone a previous attempt at repair. As an add-on code, it can be billed only in addition to other, specific procedures.

Before January 1, code 57267 could only be reported with an anterior or posterior colporrhaphy, or both, or with a rectocele repair without colporrhaphy.

When performing a vaginal approach paravaginal defect repair, however, the same weakened tissues also require use of the mesh, yet code 57825 (paravaginal defect repair [including repair of cystocele, if performed]) was not included as one of the allowed codes. This error is rectified in 2009.

You must still be aware that reporting the 57267 add-on code requires that you establish medical necessity for its use. Documentation of weakened, attenuated, or incompetent pubocervical tissue in the case of a paravaginal repair (International Classification of Diseases Clinical Modification [ICD-9-CM] code 618.81) or rectovaginal tissue for rectocele/enterocele repair (618.82) continues to be important when reporting the add-on mesh code.

A reminder about anesthesia

Until January 1, codes 57400 (dilation of vagina), 57410 (pelvic examination), and 57415 (removal of impacted vaginal foreign body) read “under anesthesia.” In a move to standardize terminology, these codes will be revised to add the wording “other than local.” The revision clarifies that 1) all surgical codes include administration of a local anesthetic and 2) codes designated with “under anesthesia” refer to regional blocks and general anesthesia.

New human papillomavirus vaccine, new code

A new code, 90650, has been added to report the newer bivalent human papillomavirus (HPV) vaccine, which contains an adjuvant formulation and is intended to protect against infection by high-risk HPV types 16 and 18. The existing HPV vaccine code, 90649, targets those high-risk types of HPV and two low-risk types (6 and 11).

Coverage recommendations for the new vaccine match those of the existing, quadrivalent vaccine, but not all payers are covering the HPV vaccine based on those recommendations. The new vaccine offers a less costly alternative for patients whose health-care insurance does not cover the vaccine or who are uninsured.

Wholesale reorganization of injection and infusion codes

Codes 90760–90779 (covering therapeutic, prophylactic, and diagnostic injections and infusions) are deleted in 2009 and renumbered, with the same descriptors, to 96360–96379. This was done to organize all infusions and injections together. The biggest change for you and every other ObGyn? You must revise the practice’s encounter form to reflect the requirement that intramuscular and subcutaneous injections are now coded 96372 instead of 90772.

Modifier -21 and prolonged E/M services

Now deleted is Modifier -21 (prolonged evaluation and management [E/M] service). This modifier represented acknowledgment that a continuous face-to-face E/M service could exceed the maximum time allowed by the highest level of E/M service for the type being billed.

In other words, before January 1, 2009, if a patient’s condition was such that you documented an established or new patient visit (99215 or 99205) but in fact spent more time with her than the 45 or 60 minutes that typically accompanies these codes, you added modifier -21 in the hope of receiving higher reimbursement. Now the modifier is deleted because there is already a mechanism in place to report such prolonged service.

Add-on codes 99354–99357 are used to report face-to-face outpatient and inpatient prolonged E/M services. Guidelines for these codes mandate cumulative time rather than continuous time, and using the add-on codes is contingent on the additional time spent being 30 or more minutes above the typical time allotted for the basic E/M service that you are billing.

Here’s a case that exemplifies how coding works in these circumstances:

CASE

You evaluate a patient for severe uterine bleeding, and report a level-4 visit (99214), which has a typical time of 25 minutes. At the same visit, you determine that endometrial biopsy is required, and you perform it during the visit. But the patient faints during the procedure—and you spend an additional 35 minutes (cumulative time) with her before you send her home.

Because the typical time of 25 minutes was exceeded by at least 30 minutes, you should report 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for office or other outpatient Evaluation and Management service]) in addition to 99214.

Guidelines for correct use of these codes are also being revised to emphasize that only outpatient prolonged services codes are intended to be used to report total duration of face-to-face time; on the other hand, inpatient codes are intended to report the total duration of the time spent (whether continuous or noncontinuous) by the physician on the unit actively involved in caring for the patient.

Take note, ObGyns: A number of changes in Current Procedural Terminology (CPT) 2009—those changes took effect January 1—are going to modify the way you bill and will have an impact on your reimbursement. Most of these changes are minor, although renumbering of infusion codes will require changes to the encounter form. And I have good and bad news for urogynecologists who perform vaginal paravaginal repairs and sling procedures for stress urinary incontinence. Read on for details!

Mesh for vaginal paravaginal defect repair—
code error corrected

Code 57267 is an add-on code that describes the insertion of mesh, or other prosthesis, through a vaginal approach when native tissues have been determined to be weak and inadequate for repair—especially in patients who have undergone a previous attempt at repair. As an add-on code, it can be billed only in addition to other, specific procedures.

Before January 1, code 57267 could only be reported with an anterior or posterior colporrhaphy, or both, or with a rectocele repair without colporrhaphy.

When performing a vaginal approach paravaginal defect repair, however, the same weakened tissues also require use of the mesh, yet code 57825 (paravaginal defect repair [including repair of cystocele, if performed]) was not included as one of the allowed codes. This error is rectified in 2009.

You must still be aware that reporting the 57267 add-on code requires that you establish medical necessity for its use. Documentation of weakened, attenuated, or incompetent pubocervical tissue in the case of a paravaginal repair (International Classification of Diseases Clinical Modification [ICD-9-CM] code 618.81) or rectovaginal tissue for rectocele/enterocele repair (618.82) continues to be important when reporting the add-on mesh code.

A reminder about anesthesia

Until January 1, codes 57400 (dilation of vagina), 57410 (pelvic examination), and 57415 (removal of impacted vaginal foreign body) read “under anesthesia.” In a move to standardize terminology, these codes will be revised to add the wording “other than local.” The revision clarifies that 1) all surgical codes include administration of a local anesthetic and 2) codes designated with “under anesthesia” refer to regional blocks and general anesthesia.

New human papillomavirus vaccine, new code

A new code, 90650, has been added to report the newer bivalent human papillomavirus (HPV) vaccine, which contains an adjuvant formulation and is intended to protect against infection by high-risk HPV types 16 and 18. The existing HPV vaccine code, 90649, targets those high-risk types of HPV and two low-risk types (6 and 11).

Coverage recommendations for the new vaccine match those of the existing, quadrivalent vaccine, but not all payers are covering the HPV vaccine based on those recommendations. The new vaccine offers a less costly alternative for patients whose health-care insurance does not cover the vaccine or who are uninsured.

Wholesale reorganization of injection and infusion codes

Codes 90760–90779 (covering therapeutic, prophylactic, and diagnostic injections and infusions) are deleted in 2009 and renumbered, with the same descriptors, to 96360–96379. This was done to organize all infusions and injections together. The biggest change for you and every other ObGyn? You must revise the practice’s encounter form to reflect the requirement that intramuscular and subcutaneous injections are now coded 96372 instead of 90772.

Modifier -21 and prolonged E/M services

Now deleted is Modifier -21 (prolonged evaluation and management [E/M] service). This modifier represented acknowledgment that a continuous face-to-face E/M service could exceed the maximum time allowed by the highest level of E/M service for the type being billed.

In other words, before January 1, 2009, if a patient’s condition was such that you documented an established or new patient visit (99215 or 99205) but in fact spent more time with her than the 45 or 60 minutes that typically accompanies these codes, you added modifier -21 in the hope of receiving higher reimbursement. Now the modifier is deleted because there is already a mechanism in place to report such prolonged service.

Add-on codes 99354–99357 are used to report face-to-face outpatient and inpatient prolonged E/M services. Guidelines for these codes mandate cumulative time rather than continuous time, and using the add-on codes is contingent on the additional time spent being 30 or more minutes above the typical time allotted for the basic E/M service that you are billing.

Here’s a case that exemplifies how coding works in these circumstances:

CASE

You evaluate a patient for severe uterine bleeding, and report a level-4 visit (99214), which has a typical time of 25 minutes. At the same visit, you determine that endometrial biopsy is required, and you perform it during the visit. But the patient faints during the procedure—and you spend an additional 35 minutes (cumulative time) with her before you send her home.

Because the typical time of 25 minutes was exceeded by at least 30 minutes, you should report 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for office or other outpatient Evaluation and Management service]) in addition to 99214.

Guidelines for correct use of these codes are also being revised to emphasize that only outpatient prolonged services codes are intended to be used to report total duration of face-to-face time; on the other hand, inpatient codes are intended to report the total duration of the time spent (whether continuous or noncontinuous) by the physician on the unit actively involved in caring for the patient.

The author reports no financial relationships relevant to this article.

OBs get codes for unremarkable sonograms ordered on the basis of suspicion. For gyn practice, options expand for abnormal Pap smear results. Here are the details.

Revisions and additions to the International Classification of Diseases, Clinical Modification (ICD-9-CM) for 2009, which take effect on October 1, 2008, bring especially good news to obstetricians who are testing for “conditions not found,” evaluating or treating twin-to-twin transfusion syndrome, dealing with the aftermath of maternal surgery, and providing the correct diagnostic code match for screening tests.

Gyn practitioners, don’t feel slighted: Many new codes take effect on that October day, covering abnormal Pap smear results, prophylactic drug treatment, breast conditions, and taking a patient’s personal history.

Remember: 1) October 1 is the key date here—when all the new and revised codes described in this article (and others not reviewed here) are added to the national code set, and 2) as in past years, there will be no grace period!

New and revised OB codes

FOR “CONDITIONS NOT FOUND”

How many times have you ordered a sonogram for a suspected problem with a pregnancy, only to have the scan reveal that all is normal? You then had to use either 1) a screening code for the condition or 2) an unspecified code because you could not assign a code that gave a condition to the patient that she did not have.

With addition of a new category of codes (V89), this obstetrical problem will be solved.

V89.01  Suspected problem with amniotic cavity and membrane not found

V89.02  Suspected placenta not found

V89.03  Suspected fetal anomaly not found

V89.04  Suspected problem with fetal growth not found

V89.05  Suspected cervical shortening not found

V89.09  Other suspected maternal and fetal condition not found

CERVICAL SHORTENING

Women undergo cervical shortening normally as their body prepares for labor, of course, but, on occasion, cervical shortening can indicate impending premature birth. Until now, you might have reflected this condition with 654.5x (Cervical incompetence complicating pregnancy), 654.6x (Other congenital or acquired abnormality of cervix), or 644.1x (Other threatened labor). Starting October 1, however, you’ll have a more precise code available to report this condition: 649.7x (Cervical shortening).

HIGH-RISK PREGNANCY

The V23 category of codes, which represent supervision of high-risk pregnancy, becomes more specific with two additions: V23.85 (Pregnancy resulting from assisted reproductive technology) and V23.86 (Pregnancy with history of in utero procedure during previous pregnancy).

ANTENATAL SCREENING

How to select the right code to report a screening test has been less than clear. Were you performing it to screen for malformation of a fetus? Some other reason? Three new antenatal codes and revision of an existing code (V28.3) clarify the distinction.

V28.3  Encounter for routine screening for malformation using ultrasonics

V28.81  Encounter for fetal anatomic survey

V28.82  Encounter for screening for risk of preterm labor

V28.89  Other specified antenatal screening

ICD-9-CM now directs that the latter code, V28.89, be reported for screening as part of chorionic villus sampling, nuchal translucency testing, genomic screening, and proteomic screening.

COMPLICATIONS OF PREGNANCY AND IN UTERO PROCEDURES

At last, you have a specific code for fetal conjoined twins (678.1x) and one for such fetal hematologic conditions as fetal anemia, thrombocytopenia, and twin-to-twin transfusion syndrome (678.0x).

In addition, complications from an in utero procedure will have two new codes: 679.0x (Maternal complications from in utero procedure) and 679.1x (Fetal complications from in utero procedure).

Gynecologic code changes and additions

ABNORMAL RESULTS OF A PAP SMEAR

You already know to look at the 795 series for ICD-9 codes to support various abnormal Pap smear results; after October 1, you’ll have a lot of new options.

Key developments:

• The risk of dysplasia and carcinoma is the same for the anus as it is for the cervix, so physicians can take anal cytologic smears.
  
• The cervix and the anus both have transformation zones where mucosa turns from squamous to columnar, so parallel codes have been created for anal smears.
  

The new codes are listed below.

CERVIX

795.07  Satisfactory cervical smear but lacking transformation zone

VAGINA AND VULVA

795.10  Abnormal Papanicolaou smear of vagina

795.11  Papanicolaou smear of vagina with atypical squamous cells of undetermined significance (ASC-US)

795.12  Papanicolaou smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)

795.13  Papanicolaou smear of vagina with low grade squamous intraepithelial lesion (LGSIL)

795.14  Papanicolaou smear of vagina with high grade squamous intraepithelial lesion (HGSIL)

795.15  Vaginal high risk papillomavirus (HPV) DNA test positive

795.16  Papanicolaou smear of vagina with cytologic evidence of malignancy

795.18  Unsatisfactory cytology smear

795.19  Other abnormal smear of vagina and vaginal HPV

ANUS

796.70  Abnormal glandular Papanicolaou smear of anus

796.71  Papanicolaou smear of anus with atypical squamous cells of undetermined significance (ASC-US)

796.72  Papanicolaou smear of anus with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)

796.73  Papanicolaou smear of anus with low grade squamous intraepithelial lesion (LGSIL)

796.74  Papanicolaou smear of anus with high grade squamous intraepithelial lesion (HGSIL)

796.75  Anal high risk human papillomavirus (HPV) DNA test positive

796.76  Papanicolaou smear of anus with cytologic evidence of malignancy

796.77  Satisfactory anal smear but lacking transformation zone

796.78  Unsatisfactory anal cytology smear

796.79  Other abnormal Papanicolaou smear of anus and anal HPV

There is also a new code, 569.44 (Dysplasia of anus), to report anal dysplasia. In the past, this condition was reported using 569.49 (Other specified disorders of rectum and anus).

ACQUIRED ABSENCE CODES

Until now, only V45.77 (Acquired absence of genital organs) could be used to report this patient status. As of October 1, you’ll have to be more specific about what is absent, using any of the following three new codes. You might find these codes helpful in supporting the performance of screening Pap smears:

V88.01  Acquired absence of both cervix and uterus

V88.02  Acquired absence of uterus with remaining cervical stump

V88.03  Acquired absence of cervix with remaining uterus

These new codes can be reported in conjunction with V67.01 (Follow-up vaginal Pap smear) and V76.47 (Special screening for malignant neoplasm of vagina).

URINARY PROBLEMS

Use these three new codes to report various presentations of hematuria:

599.70  Hematuria, unspecified

599.71  Gross hematuria

599.72  Microscopic hematuria

Note: The old code for hematuria (599.7) did not require a fifth digit; after October 1, using that old code will trigger a denial of your claim.

In addition, you have two new codes with which to report urinary symptoms:

788.91  Functional urinary incontinence

788.99  Other symptoms involving urinary symptoms

VULVODYNIA AND VULVAR VESTIBULITIS

A single code (625.8) has been available to describe vulvodynia, and it was grouped into a general category that covered symptoms. This condition has been given three new codes.

625.70  Vulvodynia, unspecified

625.71  Vulvar vestibulitis

625.79  Other vulvodynia

BREAST DISORDERS

New codes for breast conditions are about to take effect. These include ptosis (611.81), hypoplasia (611.82), and other disorders of the breast, such as capsular contracture of a breast implant (611.89).

For surgeons who handle follow-up after breast surgery, two new codes describe problems with the reconstructed breast: 612.0 (Deformity of reconstructed breast) and 612.1 (Disproportion of reconstructed breast).

WOUND DISRUPTION

Under current ICD-9-CM guidelines, you must specify “external wound” or “internal wound” to code correctly for dehiscence. On October 1, you have the option to report an unspecified code, 998.30 (Disruption of wound, unspecified) if the record does not specify the type of wound.

PROPHYLACTIC USE OF AGENTS AFFECTING ESTROGEN RECEPTORS AND ESTROGEN LEVELS

ICD-9-CM created a V code to capture data on the many women who receive tamoxifen and raloxifene after treatment of breast cancer. This code has been expanded to include V codes for different classes of drugs used for this type of therapy:

V07.51  Prophylactic use of selective estrogen receptor modulators (SERMs)

V07.52  Prophylactic use of aromatase inhibitors

V07.59  Prophylactic use of agents affecting estrogen receptors and estrogen levels

From a guideline perspective, you can use the cancer code with one of these codes throughout the course of treatment, including during routine chemotherapy and radiation therapy. Long-term use of a drug that falls under the V07.5x category doesn’t require continued use of the cancer code, however.

You can provide additional information on your patient by reporting her estrogen receptor-positive status (V86.0), personal or family history of breast cancer (V10.3/V16.3), genetic susceptibility to cancer (V84.01–V84.09), and postmenopausal status (V49.81).

TAKING A PERSONAL HISTORY

This year, 11 codes make their debut to allow you to report a patient’s personal history. Use them for encounters in which the personal history has a direct impact on the patient’s complaints or status.

V13.51  Personal history of pathologic fracture

V13.52  Personal history of stress fracture

V13.59  Personal history of other musculoskeletal disorders

V15.51  Personal history of traumatic fracture

V15.59  Personal history of other injury

V15.21  Personal history of undergoing in utero procedure during pregnancy

V15.22  Personal history of undergoing in utero procedure while a fetus

V15.29  Personal history of surgery to other organs

V87.41  Personal history of antineoplastic chemotherapy

V87.42  Personal history of monoclonal drug therapy

V87.49  Personal history of other drug therapy

The author reports no financial relationships relevant to this article.

OBs get codes for unremarkable sonograms ordered on the basis of suspicion. For gyn practice, options expand for abnormal Pap smear results. Here are the details.

Revisions and additions to the International Classification of Diseases, Clinical Modification (ICD-9-CM) for 2009, which take effect on October 1, 2008, bring especially good news to obstetricians who are testing for “conditions not found,” evaluating or treating twin-to-twin transfusion syndrome, dealing with the aftermath of maternal surgery, and providing the correct diagnostic code match for screening tests.

Gyn practitioners, don’t feel slighted: Many new codes take effect on that October day, covering abnormal Pap smear results, prophylactic drug treatment, breast conditions, and taking a patient’s personal history.

Remember: 1) October 1 is the key date here—when all the new and revised codes described in this article (and others not reviewed here) are added to the national code set, and 2) as in past years, there will be no grace period!

New and revised OB codes

FOR “CONDITIONS NOT FOUND”

How many times have you ordered a sonogram for a suspected problem with a pregnancy, only to have the scan reveal that all is normal? You then had to use either 1) a screening code for the condition or 2) an unspecified code because you could not assign a code that gave a condition to the patient that she did not have.

With addition of a new category of codes (V89), this obstetrical problem will be solved.

V89.01  Suspected problem with amniotic cavity and membrane not found

V89.02  Suspected placenta not found

V89.03  Suspected fetal anomaly not found

V89.04  Suspected problem with fetal growth not found

V89.05  Suspected cervical shortening not found

V89.09  Other suspected maternal and fetal condition not found

CERVICAL SHORTENING

Women undergo cervical shortening normally as their body prepares for labor, of course, but, on occasion, cervical shortening can indicate impending premature birth. Until now, you might have reflected this condition with 654.5x (Cervical incompetence complicating pregnancy), 654.6x (Other congenital or acquired abnormality of cervix), or 644.1x (Other threatened labor). Starting October 1, however, you’ll have a more precise code available to report this condition: 649.7x (Cervical shortening).

HIGH-RISK PREGNANCY

The V23 category of codes, which represent supervision of high-risk pregnancy, becomes more specific with two additions: V23.85 (Pregnancy resulting from assisted reproductive technology) and V23.86 (Pregnancy with history of in utero procedure during previous pregnancy).

ANTENATAL SCREENING

How to select the right code to report a screening test has been less than clear. Were you performing it to screen for malformation of a fetus? Some other reason? Three new antenatal codes and revision of an existing code (V28.3) clarify the distinction.

V28.3  Encounter for routine screening for malformation using ultrasonics

V28.81  Encounter for fetal anatomic survey

V28.82  Encounter for screening for risk of preterm labor

V28.89  Other specified antenatal screening

ICD-9-CM now directs that the latter code, V28.89, be reported for screening as part of chorionic villus sampling, nuchal translucency testing, genomic screening, and proteomic screening.

COMPLICATIONS OF PREGNANCY AND IN UTERO PROCEDURES

At last, you have a specific code for fetal conjoined twins (678.1x) and one for such fetal hematologic conditions as fetal anemia, thrombocytopenia, and twin-to-twin transfusion syndrome (678.0x).

In addition, complications from an in utero procedure will have two new codes: 679.0x (Maternal complications from in utero procedure) and 679.1x (Fetal complications from in utero procedure).

Gynecologic code changes and additions

ABNORMAL RESULTS OF A PAP SMEAR

You already know to look at the 795 series for ICD-9 codes to support various abnormal Pap smear results; after October 1, you’ll have a lot of new options.

Key developments:

• The risk of dysplasia and carcinoma is the same for the anus as it is for the cervix, so physicians can take anal cytologic smears.
  
• The cervix and the anus both have transformation zones where mucosa turns from squamous to columnar, so parallel codes have been created for anal smears.
  

The new codes are listed below.

CERVIX

795.07  Satisfactory cervical smear but lacking transformation zone

VAGINA AND VULVA

795.10  Abnormal Papanicolaou smear of vagina

795.11  Papanicolaou smear of vagina with atypical squamous cells of undetermined significance (ASC-US)

795.12  Papanicolaou smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)

795.13  Papanicolaou smear of vagina with low grade squamous intraepithelial lesion (LGSIL)

795.14  Papanicolaou smear of vagina with high grade squamous intraepithelial lesion (HGSIL)

795.15  Vaginal high risk papillomavirus (HPV) DNA test positive

795.16  Papanicolaou smear of vagina with cytologic evidence of malignancy

795.18  Unsatisfactory cytology smear

795.19  Other abnormal smear of vagina and vaginal HPV

ANUS

796.70  Abnormal glandular Papanicolaou smear of anus

796.71  Papanicolaou smear of anus with atypical squamous cells of undetermined significance (ASC-US)

796.72  Papanicolaou smear of anus with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)

796.73  Papanicolaou smear of anus with low grade squamous intraepithelial lesion (LGSIL)

796.74  Papanicolaou smear of anus with high grade squamous intraepithelial lesion (HGSIL)

796.75  Anal high risk human papillomavirus (HPV) DNA test positive

796.76  Papanicolaou smear of anus with cytologic evidence of malignancy

796.77  Satisfactory anal smear but lacking transformation zone

796.78  Unsatisfactory anal cytology smear

796.79  Other abnormal Papanicolaou smear of anus and anal HPV

There is also a new code, 569.44 (Dysplasia of anus), to report anal dysplasia. In the past, this condition was reported using 569.49 (Other specified disorders of rectum and anus).

ACQUIRED ABSENCE CODES

Until now, only V45.77 (Acquired absence of genital organs) could be used to report this patient status. As of October 1, you’ll have to be more specific about what is absent, using any of the following three new codes. You might find these codes helpful in supporting the performance of screening Pap smears:

V88.01  Acquired absence of both cervix and uterus

V88.02  Acquired absence of uterus with remaining cervical stump

V88.03  Acquired absence of cervix with remaining uterus

These new codes can be reported in conjunction with V67.01 (Follow-up vaginal Pap smear) and V76.47 (Special screening for malignant neoplasm of vagina).

URINARY PROBLEMS

Use these three new codes to report various presentations of hematuria:

599.70  Hematuria, unspecified

599.71  Gross hematuria

599.72  Microscopic hematuria

Note: The old code for hematuria (599.7) did not require a fifth digit; after October 1, using that old code will trigger a denial of your claim.

In addition, you have two new codes with which to report urinary symptoms:

788.91  Functional urinary incontinence

788.99  Other symptoms involving urinary symptoms

VULVODYNIA AND VULVAR VESTIBULITIS

A single code (625.8) has been available to describe vulvodynia, and it was grouped into a general category that covered symptoms. This condition has been given three new codes.

625.70  Vulvodynia, unspecified

625.71  Vulvar vestibulitis

625.79  Other vulvodynia

BREAST DISORDERS

New codes for breast conditions are about to take effect. These include ptosis (611.81), hypoplasia (611.82), and other disorders of the breast, such as capsular contracture of a breast implant (611.89).

For surgeons who handle follow-up after breast surgery, two new codes describe problems with the reconstructed breast: 612.0 (Deformity of reconstructed breast) and 612.1 (Disproportion of reconstructed breast).

WOUND DISRUPTION

Under current ICD-9-CM guidelines, you must specify “external wound” or “internal wound” to code correctly for dehiscence. On October 1, you have the option to report an unspecified code, 998.30 (Disruption of wound, unspecified) if the record does not specify the type of wound.

PROPHYLACTIC USE OF AGENTS AFFECTING ESTROGEN RECEPTORS AND ESTROGEN LEVELS

ICD-9-CM created a V code to capture data on the many women who receive tamoxifen and raloxifene after treatment of breast cancer. This code has been expanded to include V codes for different classes of drugs used for this type of therapy:

V07.51  Prophylactic use of selective estrogen receptor modulators (SERMs)

V07.52  Prophylactic use of aromatase inhibitors

V07.59  Prophylactic use of agents affecting estrogen receptors and estrogen levels

From a guideline perspective, you can use the cancer code with one of these codes throughout the course of treatment, including during routine chemotherapy and radiation therapy. Long-term use of a drug that falls under the V07.5x category doesn’t require continued use of the cancer code, however.

You can provide additional information on your patient by reporting her estrogen receptor-positive status (V86.0), personal or family history of breast cancer (V10.3/V16.3), genetic susceptibility to cancer (V84.01–V84.09), and postmenopausal status (V49.81).

TAKING A PERSONAL HISTORY

This year, 11 codes make their debut to allow you to report a patient’s personal history. Use them for encounters in which the personal history has a direct impact on the patient’s complaints or status.

V13.51  Personal history of pathologic fracture

V13.52  Personal history of stress fracture

V13.59  Personal history of other musculoskeletal disorders

V15.51  Personal history of traumatic fracture

V15.59  Personal history of other injury

V15.21  Personal history of undergoing in utero procedure during pregnancy

V15.22  Personal history of undergoing in utero procedure while a fetus

V15.29  Personal history of surgery to other organs

V87.41  Personal history of antineoplastic chemotherapy

V87.42  Personal history of monoclonal drug therapy

V87.49  Personal history of other drug therapy

The author reports no financial relationships relevant to this article.

OBs get codes for unremarkable sonograms ordered on the basis of suspicion. For gyn practice, options expand for abnormal Pap smear results. Here are the details.

Revisions and additions to the International Classification of Diseases, Clinical Modification (ICD-9-CM) for 2009, which take effect on October 1, 2008, bring especially good news to obstetricians who are testing for “conditions not found,” evaluating or treating twin-to-twin transfusion syndrome, dealing with the aftermath of maternal surgery, and providing the correct diagnostic code match for screening tests.

Gyn practitioners, don’t feel slighted: Many new codes take effect on that October day, covering abnormal Pap smear results, prophylactic drug treatment, breast conditions, and taking a patient’s personal history.

Remember: 1) October 1 is the key date here—when all the new and revised codes described in this article (and others not reviewed here) are added to the national code set, and 2) as in past years, there will be no grace period!

New and revised OB codes

FOR “CONDITIONS NOT FOUND”

How many times have you ordered a sonogram for a suspected problem with a pregnancy, only to have the scan reveal that all is normal? You then had to use either 1) a screening code for the condition or 2) an unspecified code because you could not assign a code that gave a condition to the patient that she did not have.

With addition of a new category of codes (V89), this obstetrical problem will be solved.

V89.01  Suspected problem with amniotic cavity and membrane not found

V89.02  Suspected placenta not found

V89.03  Suspected fetal anomaly not found

V89.04  Suspected problem with fetal growth not found

V89.05  Suspected cervical shortening not found

V89.09  Other suspected maternal and fetal condition not found

CERVICAL SHORTENING

Women undergo cervical shortening normally as their body prepares for labor, of course, but, on occasion, cervical shortening can indicate impending premature birth. Until now, you might have reflected this condition with 654.5x (Cervical incompetence complicating pregnancy), 654.6x (Other congenital or acquired abnormality of cervix), or 644.1x (Other threatened labor). Starting October 1, however, you’ll have a more precise code available to report this condition: 649.7x (Cervical shortening).

HIGH-RISK PREGNANCY

The V23 category of codes, which represent supervision of high-risk pregnancy, becomes more specific with two additions: V23.85 (Pregnancy resulting from assisted reproductive technology) and V23.86 (Pregnancy with history of in utero procedure during previous pregnancy).

ANTENATAL SCREENING

How to select the right code to report a screening test has been less than clear. Were you performing it to screen for malformation of a fetus? Some other reason? Three new antenatal codes and revision of an existing code (V28.3) clarify the distinction.

V28.3  Encounter for routine screening for malformation using ultrasonics

V28.81  Encounter for fetal anatomic survey

V28.82  Encounter for screening for risk of preterm labor

V28.89  Other specified antenatal screening

ICD-9-CM now directs that the latter code, V28.89, be reported for screening as part of chorionic villus sampling, nuchal translucency testing, genomic screening, and proteomic screening.

COMPLICATIONS OF PREGNANCY AND IN UTERO PROCEDURES

At last, you have a specific code for fetal conjoined twins (678.1x) and one for such fetal hematologic conditions as fetal anemia, thrombocytopenia, and twin-to-twin transfusion syndrome (678.0x).

In addition, complications from an in utero procedure will have two new codes: 679.0x (Maternal complications from in utero procedure) and 679.1x (Fetal complications from in utero procedure).

Gynecologic code changes and additions

ABNORMAL RESULTS OF A PAP SMEAR

You already know to look at the 795 series for ICD-9 codes to support various abnormal Pap smear results; after October 1, you’ll have a lot of new options.

Key developments:

• The risk of dysplasia and carcinoma is the same for the anus as it is for the cervix, so physicians can take anal cytologic smears.
  
• The cervix and the anus both have transformation zones where mucosa turns from squamous to columnar, so parallel codes have been created for anal smears.
  

The new codes are listed below.

CERVIX

795.07  Satisfactory cervical smear but lacking transformation zone

VAGINA AND VULVA

795.10  Abnormal Papanicolaou smear of vagina

795.11  Papanicolaou smear of vagina with atypical squamous cells of undetermined significance (ASC-US)

795.12  Papanicolaou smear of vagina with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)

795.13  Papanicolaou smear of vagina with low grade squamous intraepithelial lesion (LGSIL)

795.14  Papanicolaou smear of vagina with high grade squamous intraepithelial lesion (HGSIL)

795.15  Vaginal high risk papillomavirus (HPV) DNA test positive

795.16  Papanicolaou smear of vagina with cytologic evidence of malignancy

795.18  Unsatisfactory cytology smear

795.19  Other abnormal smear of vagina and vaginal HPV

ANUS

796.70  Abnormal glandular Papanicolaou smear of anus

796.71  Papanicolaou smear of anus with atypical squamous cells of undetermined significance (ASC-US)

796.72  Papanicolaou smear of anus with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H)

796.73  Papanicolaou smear of anus with low grade squamous intraepithelial lesion (LGSIL)

796.74  Papanicolaou smear of anus with high grade squamous intraepithelial lesion (HGSIL)

796.75  Anal high risk human papillomavirus (HPV) DNA test positive

796.76  Papanicolaou smear of anus with cytologic evidence of malignancy

796.77  Satisfactory anal smear but lacking transformation zone

796.78  Unsatisfactory anal cytology smear

796.79  Other abnormal Papanicolaou smear of anus and anal HPV

There is also a new code, 569.44 (Dysplasia of anus), to report anal dysplasia. In the past, this condition was reported using 569.49 (Other specified disorders of rectum and anus).

ACQUIRED ABSENCE CODES

Until now, only V45.77 (Acquired absence of genital organs) could be used to report this patient status. As of October 1, you’ll have to be more specific about what is absent, using any of the following three new codes. You might find these codes helpful in supporting the performance of screening Pap smears:

V88.01  Acquired absence of both cervix and uterus

V88.02  Acquired absence of uterus with remaining cervical stump

V88.03  Acquired absence of cervix with remaining uterus

These new codes can be reported in conjunction with V67.01 (Follow-up vaginal Pap smear) and V76.47 (Special screening for malignant neoplasm of vagina).

URINARY PROBLEMS

Use these three new codes to report various presentations of hematuria:

599.70  Hematuria, unspecified

599.71  Gross hematuria

599.72  Microscopic hematuria

Note: The old code for hematuria (599.7) did not require a fifth digit; after October 1, using that old code will trigger a denial of your claim.

In addition, you have two new codes with which to report urinary symptoms:

788.91  Functional urinary incontinence

788.99  Other symptoms involving urinary symptoms

VULVODYNIA AND VULVAR VESTIBULITIS

A single code (625.8) has been available to describe vulvodynia, and it was grouped into a general category that covered symptoms. This condition has been given three new codes.

625.70  Vulvodynia, unspecified

625.71  Vulvar vestibulitis

625.79  Other vulvodynia

BREAST DISORDERS

New codes for breast conditions are about to take effect. These include ptosis (611.81), hypoplasia (611.82), and other disorders of the breast, such as capsular contracture of a breast implant (611.89).

For surgeons who handle follow-up after breast surgery, two new codes describe problems with the reconstructed breast: 612.0 (Deformity of reconstructed breast) and 612.1 (Disproportion of reconstructed breast).

WOUND DISRUPTION

Under current ICD-9-CM guidelines, you must specify “external wound” or “internal wound” to code correctly for dehiscence. On October 1, you have the option to report an unspecified code, 998.30 (Disruption of wound, unspecified) if the record does not specify the type of wound.

PROPHYLACTIC USE OF AGENTS AFFECTING ESTROGEN RECEPTORS AND ESTROGEN LEVELS

ICD-9-CM created a V code to capture data on the many women who receive tamoxifen and raloxifene after treatment of breast cancer. This code has been expanded to include V codes for different classes of drugs used for this type of therapy:

V07.51  Prophylactic use of selective estrogen receptor modulators (SERMs)

V07.52  Prophylactic use of aromatase inhibitors

V07.59  Prophylactic use of agents affecting estrogen receptors and estrogen levels

From a guideline perspective, you can use the cancer code with one of these codes throughout the course of treatment, including during routine chemotherapy and radiation therapy. Long-term use of a drug that falls under the V07.5x category doesn’t require continued use of the cancer code, however.

You can provide additional information on your patient by reporting her estrogen receptor-positive status (V86.0), personal or family history of breast cancer (V10.3/V16.3), genetic susceptibility to cancer (V84.01–V84.09), and postmenopausal status (V49.81).

TAKING A PERSONAL HISTORY

This year, 11 codes make their debut to allow you to report a patient’s personal history. Use them for encounters in which the personal history has a direct impact on the patient’s complaints or status.

V13.51  Personal history of pathologic fracture

V13.52  Personal history of stress fracture

V13.59  Personal history of other musculoskeletal disorders

V15.51  Personal history of traumatic fracture

V15.59  Personal history of other injury

V15.21  Personal history of undergoing in utero procedure during pregnancy

V15.22  Personal history of undergoing in utero procedure while a fetus

V15.29  Personal history of surgery to other organs

V87.41  Personal history of antineoplastic chemotherapy

V87.42  Personal history of monoclonal drug therapy

V87.49  Personal history of other drug therapy

Q When we manage a patient in the hospital for premature rupture of membranes (PROM), we might decide to treat her medically or, depending on fetal age, progress to delivery at admission. Can we legitimately bill for these inpatient services outside of the global obstetric package?

A As with most issues dealing with obstetric care, the payer has the final word on what can and cannot be billed outside of global care. In the situation you describe or, for that matter, admission for any complication of pregnancy, payers generally reimburse for hospital care that occurs before the date of delivery. That includes admission and subsequent care. If you admit the patient for PROM and she goes on to deliver that day, your chances of being reimbursed for the admission diminish considerably—unless your documentation shows considerable work on your part to stop contractions and labor.

BSO for breast Ca patient—OK to code as CIS surgery?

Q I am planning to perform a laparoscopic bilateral salpingo-oophorectomy for a patient who has breast cancer. She is having surgery because she is unable to tolerate anti-estrogens. I plan on indicating the diagnosis as 233.0 and V50.42. Would these codes be correct for this surgery?

A The answer depends on whether 1) she has breast cancer now or 2) she already had treatment and you are planning the surgery to remove structures that are causing the estrogen risk. Reporting 233.0 (carcinoma in situ of the breast) signifies she has breast cancer now, and is still in treatment. If that is not the case—if treatment for in situ cancer has been completed—she instead has a history of the condition (V10.3). This coding rule can be found in the ICD-9-CM official guidelines.

In any case, your primary diagnosis would be V50.42 (prophylactic organ removal, ovary), followed by V10.3, then followed by V86.1 because she is probably estrogen-receptor positive (meaning that taking anti-estrogens will not prevent the return of cancer).

If she is still being treated for cancer in situ, then 233.0 is correct but V50.42 needs to be the primary diagnosis because, otherwise, you get a mismatch between the diagnosis and the surgery (i.e., it appears that you are performing an oophorectomy because of breast cancer).

Q When we manage a patient in the hospital for premature rupture of membranes (PROM), we might decide to treat her medically or, depending on fetal age, progress to delivery at admission. Can we legitimately bill for these inpatient services outside of the global obstetric package?

A As with most issues dealing with obstetric care, the payer has the final word on what can and cannot be billed outside of global care. In the situation you describe or, for that matter, admission for any complication of pregnancy, payers generally reimburse for hospital care that occurs before the date of delivery. That includes admission and subsequent care. If you admit the patient for PROM and she goes on to deliver that day, your chances of being reimbursed for the admission diminish considerably—unless your documentation shows considerable work on your part to stop contractions and labor.

BSO for breast Ca patient—OK to code as CIS surgery?

Q I am planning to perform a laparoscopic bilateral salpingo-oophorectomy for a patient who has breast cancer. She is having surgery because she is unable to tolerate anti-estrogens. I plan on indicating the diagnosis as 233.0 and V50.42. Would these codes be correct for this surgery?

A The answer depends on whether 1) she has breast cancer now or 2) she already had treatment and you are planning the surgery to remove structures that are causing the estrogen risk. Reporting 233.0 (carcinoma in situ of the breast) signifies she has breast cancer now, and is still in treatment. If that is not the case—if treatment for in situ cancer has been completed—she instead has a history of the condition (V10.3). This coding rule can be found in the ICD-9-CM official guidelines.

In any case, your primary diagnosis would be V50.42 (prophylactic organ removal, ovary), followed by V10.3, then followed by V86.1 because she is probably estrogen-receptor positive (meaning that taking anti-estrogens will not prevent the return of cancer).

If she is still being treated for cancer in situ, then 233.0 is correct but V50.42 needs to be the primary diagnosis because, otherwise, you get a mismatch between the diagnosis and the surgery (i.e., it appears that you are performing an oophorectomy because of breast cancer).

Q When we manage a patient in the hospital for premature rupture of membranes (PROM), we might decide to treat her medically or, depending on fetal age, progress to delivery at admission. Can we legitimately bill for these inpatient services outside of the global obstetric package?

A As with most issues dealing with obstetric care, the payer has the final word on what can and cannot be billed outside of global care. In the situation you describe or, for that matter, admission for any complication of pregnancy, payers generally reimburse for hospital care that occurs before the date of delivery. That includes admission and subsequent care. If you admit the patient for PROM and she goes on to deliver that day, your chances of being reimbursed for the admission diminish considerably—unless your documentation shows considerable work on your part to stop contractions and labor.

BSO for breast Ca patient—OK to code as CIS surgery?

Q I am planning to perform a laparoscopic bilateral salpingo-oophorectomy for a patient who has breast cancer. She is having surgery because she is unable to tolerate anti-estrogens. I plan on indicating the diagnosis as 233.0 and V50.42. Would these codes be correct for this surgery?

A The answer depends on whether 1) she has breast cancer now or 2) she already had treatment and you are planning the surgery to remove structures that are causing the estrogen risk. Reporting 233.0 (carcinoma in situ of the breast) signifies she has breast cancer now, and is still in treatment. If that is not the case—if treatment for in situ cancer has been completed—she instead has a history of the condition (V10.3). This coding rule can be found in the ICD-9-CM official guidelines.

In any case, your primary diagnosis would be V50.42 (prophylactic organ removal, ovary), followed by V10.3, then followed by V86.1 because she is probably estrogen-receptor positive (meaning that taking anti-estrogens will not prevent the return of cancer).

If she is still being treated for cancer in situ, then 233.0 is correct but V50.42 needs to be the primary diagnosis because, otherwise, you get a mismatch between the diagnosis and the surgery (i.e., it appears that you are performing an oophorectomy because of breast cancer).

Q We often are denied for ultrasonography (US) scans performed for pelvic pain (625.9). This is one of the symptoms that may indicate a problem with the uterus or ovaries, so why isn’t the payer allowing this diagnosis?

A For many payers, a diagnosis of 625.9 represents an unspecific symptom that can turn out to be something—or nothing at all. In the absence of additional diagnosis codes that more strongly indicate the need for US, many believe that medical necessity is not established.

If the patient can pinpoint which quadrant the pain is in, a better option is to report 789.0X (abdominal pain; the fifth [X] digit reports the site, such as left lower-quadrant or right upper-quadrant, etc.). Using this code more specifically identifies the complaint and location; I have found that fewer payers deny a US scan when this code is reported.

Problem with -52 modifier for US follicle evaluation

Q Our infertility practice often performs transvaginal US scans to check for follicles. We have been billing 76830 (ultrasound, transvaginal) with a -52 modifier (reduced service) instead of 76857 (ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]) and, so far, have had no problems getting paid. We also perform 76817 (ultrasound, pregnant uterus, real time with image documentation, transvaginal) with a modifier -52 for cervical checks or 76830 for endometrial thickness checks.

Can you comment on our coding strategies for these services?

A You say you are being reimbursed with “no problems”—but have you checked to see if you are being reimbursed at a reduced level? Not all payer systems do anything with a modifier -52, by way of reducing the allowed amount; if you are not being asked for additional information about the amount of work you did perform, I suspect you are being paid for the full service. This constitutes an overpayment to you for a service you did not document, according to CPT requirements.

Among payers that recognize -52, almost all put the claim into manual review before payment. If you are being paid a reduced amount, have you compared it with the reimbursement you might be getting by reporting 76857 instead? Note that neither code 76857 (which specifies checking for follicles) nor code 76815 (which specifies a limited exam such as you would perform for a quick cervical check on a pregnant patient) specifies the approach—in other words, the word “pelvic” does not imply strictly a transabdominal approach. These codes can therefore be used to report either an abdominal or transvaginal scan. In my opinion, either code more accurately describes the procedures that you are performing.

Dx/procedure mismatch when checking for fibroids

Q For an obstetric patient with fibroids, we just performed a Doppler ultrasound scan to check the vascularity of the fibroid. Can we use code 93975 (duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study) with an obstetric US code?

A Yes. You may report a duplex-Doppler scan with an obstetric US procedure because there are no bundles within the National Correct Coding Initiative that preclude your doing so. But your diagnosis code will be taken from the obstetric complications chapter (e.g., 654.13, tumors of body of uterus), which may create a mismatch in the diagnosis/procedure check in the payer’s computer. This doesn’t mean you won’t be paid for the nonobstetric sonogram being linked to an obstetric complication, but you might have to submit additional information with the claim.

Also, understand that the duplex procedures are only reported when you are trying to characterize the pattern and direction of blood flow in arteries or veins. This year, CPT clarified that, although evaluation of vascular structures using both color and spectral Doppler is reportable separately, color Doppler alone, when performed for identification of anatomic structures in conjunction with a real-time US exam, cannot be reported separately.

Last, the code you are billing, 93975, represents a complete study. Examination of a single fibroid within the uterus constitutes a limited study, billed using 93976.

Q We often are denied for ultrasonography (US) scans performed for pelvic pain (625.9). This is one of the symptoms that may indicate a problem with the uterus or ovaries, so why isn’t the payer allowing this diagnosis?

A For many payers, a diagnosis of 625.9 represents an unspecific symptom that can turn out to be something—or nothing at all. In the absence of additional diagnosis codes that more strongly indicate the need for US, many believe that medical necessity is not established.

If the patient can pinpoint which quadrant the pain is in, a better option is to report 789.0X (abdominal pain; the fifth [X] digit reports the site, such as left lower-quadrant or right upper-quadrant, etc.). Using this code more specifically identifies the complaint and location; I have found that fewer payers deny a US scan when this code is reported.

Problem with -52 modifier for US follicle evaluation

Q Our infertility practice often performs transvaginal US scans to check for follicles. We have been billing 76830 (ultrasound, transvaginal) with a -52 modifier (reduced service) instead of 76857 (ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]) and, so far, have had no problems getting paid. We also perform 76817 (ultrasound, pregnant uterus, real time with image documentation, transvaginal) with a modifier -52 for cervical checks or 76830 for endometrial thickness checks.

Can you comment on our coding strategies for these services?

A You say you are being reimbursed with “no problems”—but have you checked to see if you are being reimbursed at a reduced level? Not all payer systems do anything with a modifier -52, by way of reducing the allowed amount; if you are not being asked for additional information about the amount of work you did perform, I suspect you are being paid for the full service. This constitutes an overpayment to you for a service you did not document, according to CPT requirements.

Among payers that recognize -52, almost all put the claim into manual review before payment. If you are being paid a reduced amount, have you compared it with the reimbursement you might be getting by reporting 76857 instead? Note that neither code 76857 (which specifies checking for follicles) nor code 76815 (which specifies a limited exam such as you would perform for a quick cervical check on a pregnant patient) specifies the approach—in other words, the word “pelvic” does not imply strictly a transabdominal approach. These codes can therefore be used to report either an abdominal or transvaginal scan. In my opinion, either code more accurately describes the procedures that you are performing.

Dx/procedure mismatch when checking for fibroids

Q For an obstetric patient with fibroids, we just performed a Doppler ultrasound scan to check the vascularity of the fibroid. Can we use code 93975 (duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study) with an obstetric US code?

A Yes. You may report a duplex-Doppler scan with an obstetric US procedure because there are no bundles within the National Correct Coding Initiative that preclude your doing so. But your diagnosis code will be taken from the obstetric complications chapter (e.g., 654.13, tumors of body of uterus), which may create a mismatch in the diagnosis/procedure check in the payer’s computer. This doesn’t mean you won’t be paid for the nonobstetric sonogram being linked to an obstetric complication, but you might have to submit additional information with the claim.

Also, understand that the duplex procedures are only reported when you are trying to characterize the pattern and direction of blood flow in arteries or veins. This year, CPT clarified that, although evaluation of vascular structures using both color and spectral Doppler is reportable separately, color Doppler alone, when performed for identification of anatomic structures in conjunction with a real-time US exam, cannot be reported separately.

Last, the code you are billing, 93975, represents a complete study. Examination of a single fibroid within the uterus constitutes a limited study, billed using 93976.

Q We often are denied for ultrasonography (US) scans performed for pelvic pain (625.9). This is one of the symptoms that may indicate a problem with the uterus or ovaries, so why isn’t the payer allowing this diagnosis?

A For many payers, a diagnosis of 625.9 represents an unspecific symptom that can turn out to be something—or nothing at all. In the absence of additional diagnosis codes that more strongly indicate the need for US, many believe that medical necessity is not established.

If the patient can pinpoint which quadrant the pain is in, a better option is to report 789.0X (abdominal pain; the fifth [X] digit reports the site, such as left lower-quadrant or right upper-quadrant, etc.). Using this code more specifically identifies the complaint and location; I have found that fewer payers deny a US scan when this code is reported.

Problem with -52 modifier for US follicle evaluation

Q Our infertility practice often performs transvaginal US scans to check for follicles. We have been billing 76830 (ultrasound, transvaginal) with a -52 modifier (reduced service) instead of 76857 (ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]) and, so far, have had no problems getting paid. We also perform 76817 (ultrasound, pregnant uterus, real time with image documentation, transvaginal) with a modifier -52 for cervical checks or 76830 for endometrial thickness checks.

Can you comment on our coding strategies for these services?

A You say you are being reimbursed with “no problems”—but have you checked to see if you are being reimbursed at a reduced level? Not all payer systems do anything with a modifier -52, by way of reducing the allowed amount; if you are not being asked for additional information about the amount of work you did perform, I suspect you are being paid for the full service. This constitutes an overpayment to you for a service you did not document, according to CPT requirements.

Among payers that recognize -52, almost all put the claim into manual review before payment. If you are being paid a reduced amount, have you compared it with the reimbursement you might be getting by reporting 76857 instead? Note that neither code 76857 (which specifies checking for follicles) nor code 76815 (which specifies a limited exam such as you would perform for a quick cervical check on a pregnant patient) specifies the approach—in other words, the word “pelvic” does not imply strictly a transabdominal approach. These codes can therefore be used to report either an abdominal or transvaginal scan. In my opinion, either code more accurately describes the procedures that you are performing.

Dx/procedure mismatch when checking for fibroids

Q For an obstetric patient with fibroids, we just performed a Doppler ultrasound scan to check the vascularity of the fibroid. Can we use code 93975 (duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study) with an obstetric US code?

A Yes. You may report a duplex-Doppler scan with an obstetric US procedure because there are no bundles within the National Correct Coding Initiative that preclude your doing so. But your diagnosis code will be taken from the obstetric complications chapter (e.g., 654.13, tumors of body of uterus), which may create a mismatch in the diagnosis/procedure check in the payer’s computer. This doesn’t mean you won’t be paid for the nonobstetric sonogram being linked to an obstetric complication, but you might have to submit additional information with the claim.

Also, understand that the duplex procedures are only reported when you are trying to characterize the pattern and direction of blood flow in arteries or veins. This year, CPT clarified that, although evaluation of vascular structures using both color and spectral Doppler is reportable separately, color Doppler alone, when performed for identification of anatomic structures in conjunction with a real-time US exam, cannot be reported separately.

Last, the code you are billing, 93975, represents a complete study. Examination of a single fibroid within the uterus constitutes a limited study, billed using 93976.

Q. Our practice is considering reporting quality measures to Medicare in 2008. Except for those relating to stress incontinence, however, there do not seem to be many that apply to ObGyn practices. Is it worth our while to even try for the bonus reimbursements promised by the program?

A. A resounding “Yes!” It isn’t just Medicare that’s looking to reward medical practices for reporting quality measures: Many larger payers are also eyeing these data to ensure top-quality care for their beneficiaries.

In the July 2007 issue of OBG Management, I wrote an article about the Medicare Physician Quality Reporting Initiative (PQRI) program, which could have earned you as much as a 1.5% bonus at the end of that year (read this article). For 2008, there are many more quality measures for which you can qualify.

For example, there are now measures for screening, such as colon cancer screening and mammography. And more:

• New measure 113 allows you to note that you documented the result of a fecal occult blood test
  
• If you document, at the time of a problem visit, the result of a recent mammogram, you can report measure 112
  
• Measures 114 and 115 relate to inquiring about a patient’s tobacco use and then advising her to quit—activities customarily performed by ObGyns.
  

For details on how to participate in this program (and to see how easy it is to report measures), visit the Centers for Medicare & Medicaid Services (CMS) at www.cms.hhs.gov/PQRI/35_2008PQRI-Information.asp. Download “2008 PRQI Quality Measure Specifications.”

Reimbursement for repair of your surgical injury?

Q. If the bladder or bowel, or a ureter or blood vessel, is injured during surgery, what are the best coding options for handling repair?

A. The answer depends largely on 1) the policy of the particular payer and 2) when the injury is repaired.

When the injury occurs during the surgery and is repaired at that time, Medicare does not allow the surgeon who caused the injury to bill separately for repairing it. If another physician is called in to make the repair, however, he (she) is reimbursed for the work. According to Medicare’s General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, “When a complication described by codes defining complications arises during an operative session…a separate service for treating the complication is not to be reported.”

A return to the operating room for a complication would be reimbursed, however; report this by adding a modifier -78 to the surgical code for the complication repair (for example, 49002 [re-opening of a recent laparotomy for hemorrhage exploration]).

Most private payers allow separate billing for repair of iatrogenic injury.

Q. Our practice is considering reporting quality measures to Medicare in 2008. Except for those relating to stress incontinence, however, there do not seem to be many that apply to ObGyn practices. Is it worth our while to even try for the bonus reimbursements promised by the program?

A. A resounding “Yes!” It isn’t just Medicare that’s looking to reward medical practices for reporting quality measures: Many larger payers are also eyeing these data to ensure top-quality care for their beneficiaries.

In the July 2007 issue of OBG Management, I wrote an article about the Medicare Physician Quality Reporting Initiative (PQRI) program, which could have earned you as much as a 1.5% bonus at the end of that year (read this article). For 2008, there are many more quality measures for which you can qualify.

For example, there are now measures for screening, such as colon cancer screening and mammography. And more:

• New measure 113 allows you to note that you documented the result of a fecal occult blood test
  
• If you document, at the time of a problem visit, the result of a recent mammogram, you can report measure 112
  
• Measures 114 and 115 relate to inquiring about a patient’s tobacco use and then advising her to quit—activities customarily performed by ObGyns.
  

For details on how to participate in this program (and to see how easy it is to report measures), visit the Centers for Medicare & Medicaid Services (CMS) at www.cms.hhs.gov/PQRI/35_2008PQRI-Information.asp. Download “2008 PRQI Quality Measure Specifications.”

Reimbursement for repair of your surgical injury?

Q. If the bladder or bowel, or a ureter or blood vessel, is injured during surgery, what are the best coding options for handling repair?

A. The answer depends largely on 1) the policy of the particular payer and 2) when the injury is repaired.

When the injury occurs during the surgery and is repaired at that time, Medicare does not allow the surgeon who caused the injury to bill separately for repairing it. If another physician is called in to make the repair, however, he (she) is reimbursed for the work. According to Medicare’s General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, “When a complication described by codes defining complications arises during an operative session…a separate service for treating the complication is not to be reported.”

A return to the operating room for a complication would be reimbursed, however; report this by adding a modifier -78 to the surgical code for the complication repair (for example, 49002 [re-opening of a recent laparotomy for hemorrhage exploration]).

Most private payers allow separate billing for repair of iatrogenic injury.

Q. Our practice is considering reporting quality measures to Medicare in 2008. Except for those relating to stress incontinence, however, there do not seem to be many that apply to ObGyn practices. Is it worth our while to even try for the bonus reimbursements promised by the program?

A. A resounding “Yes!” It isn’t just Medicare that’s looking to reward medical practices for reporting quality measures: Many larger payers are also eyeing these data to ensure top-quality care for their beneficiaries.

In the July 2007 issue of OBG Management, I wrote an article about the Medicare Physician Quality Reporting Initiative (PQRI) program, which could have earned you as much as a 1.5% bonus at the end of that year (read this article). For 2008, there are many more quality measures for which you can qualify.

For example, there are now measures for screening, such as colon cancer screening and mammography. And more:

• New measure 113 allows you to note that you documented the result of a fecal occult blood test
  
• If you document, at the time of a problem visit, the result of a recent mammogram, you can report measure 112
  
• Measures 114 and 115 relate to inquiring about a patient’s tobacco use and then advising her to quit—activities customarily performed by ObGyns.
  

For details on how to participate in this program (and to see how easy it is to report measures), visit the Centers for Medicare & Medicaid Services (CMS) at www.cms.hhs.gov/PQRI/35_2008PQRI-Information.asp. Download “2008 PRQI Quality Measure Specifications.”

Reimbursement for repair of your surgical injury?

Q. If the bladder or bowel, or a ureter or blood vessel, is injured during surgery, what are the best coding options for handling repair?

A. The answer depends largely on 1) the policy of the particular payer and 2) when the injury is repaired.

When the injury occurs during the surgery and is repaired at that time, Medicare does not allow the surgeon who caused the injury to bill separately for repairing it. If another physician is called in to make the repair, however, he (she) is reimbursed for the work. According to Medicare’s General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, “When a complication described by codes defining complications arises during an operative session…a separate service for treating the complication is not to be reported.”

A return to the operating room for a complication would be reimbursed, however; report this by adding a modifier -78 to the surgical code for the complication repair (for example, 49002 [re-opening of a recent laparotomy for hemorrhage exploration]).

Most private payers allow separate billing for repair of iatrogenic injury.

Old codes 99371–99373 that were used to report a call you made to a patient, or to consult or coordinate medical management with other health-care professionals, are deleted in 2008. In their place? A series of new codes that cover not only physician–patient contact but nonphysician–patient contact on the telephone.

Additional codes have also been added for non–face-to-face physician– provider contact regarding the care of a patient. Although these new codes may not be reimbursed by many payers, they do allow you to bill the patient for such services in many instances. They’ll also help the practice better track the care given by its providers.

Patient-initiated telephone contact

99441  Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion

99442  …11–20 minutes of medical discussion

99443  …21–30 minutes of medical discussion

98966   Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion

98967  …11–20 minutes of medical discussion

98968  …21–30 minutes of medical discussion

To use these codes, keep in mind a few rules:

• Contact must be initiated by the patient or the established patient’s guardian
  
• Don’t report the new codes if the patient is then seen for the problem within 24 hours after the call or at the next available urgent appointment. When that happens, the call is considered part of the pre-service work and may be counted as part of the billable E/M service
  
• Don’t report the new codes if the call relates to an E/M service that was reported by the provider within the prior 7 days—whether the provider did or did not request that the call be made
  
• Don’t report the new codes for any follow-up regarding a procedure that was performed while the patient is still in the postop period.
  

Conferring with the medical team

99367   Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician

99368  …participation by nonphysician qualified health care professional

The interactions of an interdisciplinary team are more comprehensive and complex than the conversations that might take place during a regular E/M service. So, the rules for these codes are somewhat different:

• The patient must be an established patient who has a chronic health condition or multiple health conditions that require a team approach to manage
  
• The participants in the conference are familiar with the patient and have seen the patient within 60 days prior to the conference call
  
• Only one provider from the same specialty may report these codes for each conference
  
• The conference must be at least 30 minutes long; the clock starts at the beginning of the review of the patient’s case and ends at the conclusion of that review. Time spent writing reports on the conference can’t be counted.
  

Providing your services online

99444  Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network

98969  Online assessment and management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network

Just as telephone calls are becoming a more common method of communicating with providers, online medical services are tracing a similar pattern of use. The Internet has allowed many patients to contact their physician (or nonphysician provider) directly; with assurances of privacy offered by current Internet communications systems, information can be readily shared between patient and physician.

Criteria for using these new codes are:

• The established patient or her guardian must have initiated the online evaluation request
  
• The provider’s response must be timely and must include permanent electronic or hard-copy documentation of the encounter
  
• The online service can only be reported once during a 7-day period for the same problem, but more than one provider can report his (her) separate online communication with the patient
  
• As with the rules for telephone contact with a patient, do not report the new codes if the provider has billed an E/M service related to the online query within the prior 7 days or within the postop period of a procedure.
  

Old codes 99371–99373 that were used to report a call you made to a patient, or to consult or coordinate medical management with other health-care professionals, are deleted in 2008. In their place? A series of new codes that cover not only physician–patient contact but nonphysician–patient contact on the telephone.

Additional codes have also been added for non–face-to-face physician– provider contact regarding the care of a patient. Although these new codes may not be reimbursed by many payers, they do allow you to bill the patient for such services in many instances. They’ll also help the practice better track the care given by its providers.

Patient-initiated telephone contact

99441  Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion

99442  …11–20 minutes of medical discussion

99443  …21–30 minutes of medical discussion

98966   Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion

98967  …11–20 minutes of medical discussion

98968  …21–30 minutes of medical discussion

To use these codes, keep in mind a few rules:

• Contact must be initiated by the patient or the established patient’s guardian
  
• Don’t report the new codes if the patient is then seen for the problem within 24 hours after the call or at the next available urgent appointment. When that happens, the call is considered part of the pre-service work and may be counted as part of the billable E/M service
  
• Don’t report the new codes if the call relates to an E/M service that was reported by the provider within the prior 7 days—whether the provider did or did not request that the call be made
  
• Don’t report the new codes for any follow-up regarding a procedure that was performed while the patient is still in the postop period.
  

Conferring with the medical team

99367   Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician

99368  …participation by nonphysician qualified health care professional

The interactions of an interdisciplinary team are more comprehensive and complex than the conversations that might take place during a regular E/M service. So, the rules for these codes are somewhat different:

• The patient must be an established patient who has a chronic health condition or multiple health conditions that require a team approach to manage
  
• The participants in the conference are familiar with the patient and have seen the patient within 60 days prior to the conference call
  
• Only one provider from the same specialty may report these codes for each conference
  
• The conference must be at least 30 minutes long; the clock starts at the beginning of the review of the patient’s case and ends at the conclusion of that review. Time spent writing reports on the conference can’t be counted.
  

Providing your services online

99444  Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network

98969  Online assessment and management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network

Just as telephone calls are becoming a more common method of communicating with providers, online medical services are tracing a similar pattern of use. The Internet has allowed many patients to contact their physician (or nonphysician provider) directly; with assurances of privacy offered by current Internet communications systems, information can be readily shared between patient and physician.

Criteria for using these new codes are:

• The established patient or her guardian must have initiated the online evaluation request
  
• The provider’s response must be timely and must include permanent electronic or hard-copy documentation of the encounter
  
• The online service can only be reported once during a 7-day period for the same problem, but more than one provider can report his (her) separate online communication with the patient
  
• As with the rules for telephone contact with a patient, do not report the new codes if the provider has billed an E/M service related to the online query within the prior 7 days or within the postop period of a procedure.
  

Old codes 99371–99373 that were used to report a call you made to a patient, or to consult or coordinate medical management with other health-care professionals, are deleted in 2008. In their place? A series of new codes that cover not only physician–patient contact but nonphysician–patient contact on the telephone.

Additional codes have also been added for non–face-to-face physician– provider contact regarding the care of a patient. Although these new codes may not be reimbursed by many payers, they do allow you to bill the patient for such services in many instances. They’ll also help the practice better track the care given by its providers.

Patient-initiated telephone contact

99441  Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion

99442  …11–20 minutes of medical discussion

99443  …21–30 minutes of medical discussion

98966   Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion

98967  …11–20 minutes of medical discussion

98968  …21–30 minutes of medical discussion

To use these codes, keep in mind a few rules:

• Contact must be initiated by the patient or the established patient’s guardian
  
• Don’t report the new codes if the patient is then seen for the problem within 24 hours after the call or at the next available urgent appointment. When that happens, the call is considered part of the pre-service work and may be counted as part of the billable E/M service
  
• Don’t report the new codes if the call relates to an E/M service that was reported by the provider within the prior 7 days—whether the provider did or did not request that the call be made
  
• Don’t report the new codes for any follow-up regarding a procedure that was performed while the patient is still in the postop period.
  

Conferring with the medical team

99367   Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician

99368  …participation by nonphysician qualified health care professional

The interactions of an interdisciplinary team are more comprehensive and complex than the conversations that might take place during a regular E/M service. So, the rules for these codes are somewhat different:

• The patient must be an established patient who has a chronic health condition or multiple health conditions that require a team approach to manage
  
• The participants in the conference are familiar with the patient and have seen the patient within 60 days prior to the conference call
  
• Only one provider from the same specialty may report these codes for each conference
  
• The conference must be at least 30 minutes long; the clock starts at the beginning of the review of the patient’s case and ends at the conclusion of that review. Time spent writing reports on the conference can’t be counted.
  

Providing your services online

99444  Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network

98969  Online assessment and management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network

Just as telephone calls are becoming a more common method of communicating with providers, online medical services are tracing a similar pattern of use. The Internet has allowed many patients to contact their physician (or nonphysician provider) directly; with assurances of privacy offered by current Internet communications systems, information can be readily shared between patient and physician.

Criteria for using these new codes are:

• The established patient or her guardian must have initiated the online evaluation request
  
• The provider’s response must be timely and must include permanent electronic or hard-copy documentation of the encounter
  
• The online service can only be reported once during a 7-day period for the same problem, but more than one provider can report his (her) separate online communication with the patient
  
• As with the rules for telephone contact with a patient, do not report the new codes if the provider has billed an E/M service related to the online query within the prior 7 days or within the postop period of a procedure.
  

There’s more: If you’ve been spending time on telephone or on-line counseling, codes that may get you paid for that service are about to make their debut.

Key additions and revisions to CPT for the new year are detailed in this article and in next issue’s Reimbursement Adviser.

Specify repair of paravaginal defect

57284  Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach

57285   Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach

57423  Paravaginal defect repair (including repair of cystocele, if performed); laparoscopic approach

You’ll now have to carefully document your surgical approach to repairing a paravaginal defect, thanks to creation of two new codes and revision of the existing 57284.

Several bundles are still attached to the new codes, however. CPT did remove references to “stress urinary incontinence, and/or incomplete vaginal prolapse” from the revised and new codes, but repair of a cystocele, by any method, is still included.

CPT 2008 is, therefore, listing codes that cannot be reported additionally. In general, urethropexy codes 51840, 51841, 51990, 58152, and 58267 and cystocele repair codes 57240, 57260, and 57265 should not be reported when a paravaginal defect repair is performed.

Also, be alert for any National Correct Coding Initiatives (NCCI) bundles assigned by Medicare to these new codes if they are different from the ones that will be listed by CPT. In particular, 57288 [sling operation for stress incontinence (e.g., fascia or synthetic)] was permanently bundled into 57284. (If that bundle isn’t removed in 2008, I encourage you to contact ACOG and urge the College to discuss this inappropriate bundle with Medicare administrators.)

Total lap hysterectomy

58570  Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less

58571  Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(ies)

58572  Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

58573  Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(ies)

For some time, surgeons have been able to perform a hysterectomy by completely detaching both the uterine cervix and the body of the uterus from their surrounding support structures laparoscopically, then closing the vaginal cuff via this approach as well. Before 2008, the only coding choices were laparoscopic-assisted hysterectomy codes (58550–58554) or the unlisted laparoscopic code 58578. The new codes—as with codes for any vaginal or laparoscopic approach—are selected based on 1) the documented weight of the uterus and 2) whether the fallopian tubes or ovaries have been removed.

Intraperitoneal tumors, coded by size

49203 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less

49204 …largest tumor 5.1–10.0 cm diameter

49205 …largest tumor greater than 10.0 cm diameter

In 2007, documenting the removal of intraperitoneal or retroperitoneal tumors, cysts, and endometriomas via abdominal incision was fairly simple: There were two codes and you had only to decide if removal was extensive or not.

In 2008, codes 49200 and 49201 are deleted and replaced by three new codes—each of which requires you to document the size of the largest tumor or lesion removed.

The new codes will come in handy during surgery in which the originating organ has been removed but the patient is found to have additional tumors. For example: A patient had ovarian cancer and now there are additional tumors in the abdominal cavity, but an omentectomy is not being performed. Of course, the new codes can still be used for excision or destruction of cysts or endometriomas, as well. But CPT has also listed codes that cannot be billed with the new codes: Among them are 38770 [pelvic lymphadenectomy] and 58900–58960 [surgeries performed on the ovaries]. If the new codes don’t fit the surgery, the other option for tumor debulking after the organ has been removed is to report 58957 or 58958; note, however, that these codes include omentectomy and optional pelvic lymph node sampling.

Bladder aspiration is renumbered

51100 Aspiration of bladder; by needle

51101 …by trocar or intracatheter

51102 …with insertion of suprapubic catheter

If you have the old codes for bladder aspiration memorized, relearn them. Once again, CPT tinkered with placement of codes and decided that bladder aspiration codes are placed more appropriately under “Bladder, Removal” than “Bladder, Incision.” The uses of those codes are unchanged.

Giving flu, HPV vaccines

90661 Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use

90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

90663 Influenza virus vaccine, pandemic formulation

90650 Human papillomavirus (HPV) vaccine, types 16 and 18, bivalent, 3-dose schedule, for intramuscular use

Four new codes for vaccines can be reported beginning January 1, but only those for the influenza vaccine appear in the CPT 2008 book. The code for the new bivalent HPV vaccine is a valid code for 2008 but will not appear in print until CPT 2009.

Changes made to “modifier -51” exemptions

CPT 2008 also reassessed codes that have been designated as “modifier - 51 exempt.” Typically, these are codes that do not involve significant preoperative or postoperative work. 36660 [catheterization, umbilical artery, newborn, for diagnosis or therapy] now requires a modifier when performed with other procedures, whereas 51797 [voiding pressure studies (VP); intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal)] becomes an add-on code that does not take a modifier -51. Beginning January 1, 51797 can be billed only if 51795 [voiding pressure studies (VP); bladder voiding pressure, any technique] has also been reported.

There’s more: If you’ve been spending time on telephone or on-line counseling, codes that may get you paid for that service are about to make their debut.

Key additions and revisions to CPT for the new year are detailed in this article and in next issue’s Reimbursement Adviser.

Specify repair of paravaginal defect

57284  Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach

57285   Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach

57423  Paravaginal defect repair (including repair of cystocele, if performed); laparoscopic approach

You’ll now have to carefully document your surgical approach to repairing a paravaginal defect, thanks to creation of two new codes and revision of the existing 57284.

Several bundles are still attached to the new codes, however. CPT did remove references to “stress urinary incontinence, and/or incomplete vaginal prolapse” from the revised and new codes, but repair of a cystocele, by any method, is still included.

CPT 2008 is, therefore, listing codes that cannot be reported additionally. In general, urethropexy codes 51840, 51841, 51990, 58152, and 58267 and cystocele repair codes 57240, 57260, and 57265 should not be reported when a paravaginal defect repair is performed.

Also, be alert for any National Correct Coding Initiatives (NCCI) bundles assigned by Medicare to these new codes if they are different from the ones that will be listed by CPT. In particular, 57288 [sling operation for stress incontinence (e.g., fascia or synthetic)] was permanently bundled into 57284. (If that bundle isn’t removed in 2008, I encourage you to contact ACOG and urge the College to discuss this inappropriate bundle with Medicare administrators.)

Total lap hysterectomy

58570  Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less

58571  Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(ies)

58572  Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

58573  Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(ies)

For some time, surgeons have been able to perform a hysterectomy by completely detaching both the uterine cervix and the body of the uterus from their surrounding support structures laparoscopically, then closing the vaginal cuff via this approach as well. Before 2008, the only coding choices were laparoscopic-assisted hysterectomy codes (58550–58554) or the unlisted laparoscopic code 58578. The new codes—as with codes for any vaginal or laparoscopic approach—are selected based on 1) the documented weight of the uterus and 2) whether the fallopian tubes or ovaries have been removed.

Intraperitoneal tumors, coded by size

49203 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less

49204 …largest tumor 5.1–10.0 cm diameter

49205 …largest tumor greater than 10.0 cm diameter

In 2007, documenting the removal of intraperitoneal or retroperitoneal tumors, cysts, and endometriomas via abdominal incision was fairly simple: There were two codes and you had only to decide if removal was extensive or not.

In 2008, codes 49200 and 49201 are deleted and replaced by three new codes—each of which requires you to document the size of the largest tumor or lesion removed.

The new codes will come in handy during surgery in which the originating organ has been removed but the patient is found to have additional tumors. For example: A patient had ovarian cancer and now there are additional tumors in the abdominal cavity, but an omentectomy is not being performed. Of course, the new codes can still be used for excision or destruction of cysts or endometriomas, as well. But CPT has also listed codes that cannot be billed with the new codes: Among them are 38770 [pelvic lymphadenectomy] and 58900–58960 [surgeries performed on the ovaries]. If the new codes don’t fit the surgery, the other option for tumor debulking after the organ has been removed is to report 58957 or 58958; note, however, that these codes include omentectomy and optional pelvic lymph node sampling.

Bladder aspiration is renumbered

51100 Aspiration of bladder; by needle

51101 …by trocar or intracatheter

51102 …with insertion of suprapubic catheter

If you have the old codes for bladder aspiration memorized, relearn them. Once again, CPT tinkered with placement of codes and decided that bladder aspiration codes are placed more appropriately under “Bladder, Removal” than “Bladder, Incision.” The uses of those codes are unchanged.

Giving flu, HPV vaccines

90661 Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use

90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

90663 Influenza virus vaccine, pandemic formulation

90650 Human papillomavirus (HPV) vaccine, types 16 and 18, bivalent, 3-dose schedule, for intramuscular use

Four new codes for vaccines can be reported beginning January 1, but only those for the influenza vaccine appear in the CPT 2008 book. The code for the new bivalent HPV vaccine is a valid code for 2008 but will not appear in print until CPT 2009.

Changes made to “modifier -51” exemptions

CPT 2008 also reassessed codes that have been designated as “modifier - 51 exempt.” Typically, these are codes that do not involve significant preoperative or postoperative work. 36660 [catheterization, umbilical artery, newborn, for diagnosis or therapy] now requires a modifier when performed with other procedures, whereas 51797 [voiding pressure studies (VP); intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal)] becomes an add-on code that does not take a modifier -51. Beginning January 1, 51797 can be billed only if 51795 [voiding pressure studies (VP); bladder voiding pressure, any technique] has also been reported.

There’s more: If you’ve been spending time on telephone or on-line counseling, codes that may get you paid for that service are about to make their debut.

Key additions and revisions to CPT for the new year are detailed in this article and in next issue’s Reimbursement Adviser.

Specify repair of paravaginal defect

57284  Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach

57285   Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach

57423  Paravaginal defect repair (including repair of cystocele, if performed); laparoscopic approach

You’ll now have to carefully document your surgical approach to repairing a paravaginal defect, thanks to creation of two new codes and revision of the existing 57284.

Several bundles are still attached to the new codes, however. CPT did remove references to “stress urinary incontinence, and/or incomplete vaginal prolapse” from the revised and new codes, but repair of a cystocele, by any method, is still included.

CPT 2008 is, therefore, listing codes that cannot be reported additionally. In general, urethropexy codes 51840, 51841, 51990, 58152, and 58267 and cystocele repair codes 57240, 57260, and 57265 should not be reported when a paravaginal defect repair is performed.

Also, be alert for any National Correct Coding Initiatives (NCCI) bundles assigned by Medicare to these new codes if they are different from the ones that will be listed by CPT. In particular, 57288 [sling operation for stress incontinence (e.g., fascia or synthetic)] was permanently bundled into 57284. (If that bundle isn’t removed in 2008, I encourage you to contact ACOG and urge the College to discuss this inappropriate bundle with Medicare administrators.)

Total lap hysterectomy

58570  Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less

58571  Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(ies)

58572  Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

58573  Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(ies)

For some time, surgeons have been able to perform a hysterectomy by completely detaching both the uterine cervix and the body of the uterus from their surrounding support structures laparoscopically, then closing the vaginal cuff via this approach as well. Before 2008, the only coding choices were laparoscopic-assisted hysterectomy codes (58550–58554) or the unlisted laparoscopic code 58578. The new codes—as with codes for any vaginal or laparoscopic approach—are selected based on 1) the documented weight of the uterus and 2) whether the fallopian tubes or ovaries have been removed.

Intraperitoneal tumors, coded by size

49203 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less

49204 …largest tumor 5.1–10.0 cm diameter

49205 …largest tumor greater than 10.0 cm diameter

In 2007, documenting the removal of intraperitoneal or retroperitoneal tumors, cysts, and endometriomas via abdominal incision was fairly simple: There were two codes and you had only to decide if removal was extensive or not.

In 2008, codes 49200 and 49201 are deleted and replaced by three new codes—each of which requires you to document the size of the largest tumor or lesion removed.

The new codes will come in handy during surgery in which the originating organ has been removed but the patient is found to have additional tumors. For example: A patient had ovarian cancer and now there are additional tumors in the abdominal cavity, but an omentectomy is not being performed. Of course, the new codes can still be used for excision or destruction of cysts or endometriomas, as well. But CPT has also listed codes that cannot be billed with the new codes: Among them are 38770 [pelvic lymphadenectomy] and 58900–58960 [surgeries performed on the ovaries]. If the new codes don’t fit the surgery, the other option for tumor debulking after the organ has been removed is to report 58957 or 58958; note, however, that these codes include omentectomy and optional pelvic lymph node sampling.

Bladder aspiration is renumbered

51100 Aspiration of bladder; by needle

51101 …by trocar or intracatheter

51102 …with insertion of suprapubic catheter

If you have the old codes for bladder aspiration memorized, relearn them. Once again, CPT tinkered with placement of codes and decided that bladder aspiration codes are placed more appropriately under “Bladder, Removal” than “Bladder, Incision.” The uses of those codes are unchanged.

Giving flu, HPV vaccines

90661 Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use

90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

90663 Influenza virus vaccine, pandemic formulation

90650 Human papillomavirus (HPV) vaccine, types 16 and 18, bivalent, 3-dose schedule, for intramuscular use

Four new codes for vaccines can be reported beginning January 1, but only those for the influenza vaccine appear in the CPT 2008 book. The code for the new bivalent HPV vaccine is a valid code for 2008 but will not appear in print until CPT 2009.

Changes made to “modifier -51” exemptions

CPT 2008 also reassessed codes that have been designated as “modifier - 51 exempt.” Typically, these are codes that do not involve significant preoperative or postoperative work. 36660 [catheterization, umbilical artery, newborn, for diagnosis or therapy] now requires a modifier when performed with other procedures, whereas 51797 [voiding pressure studies (VP); intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal)] becomes an add-on code that does not take a modifier -51. Beginning January 1, 51797 can be billed only if 51795 [voiding pressure studies (VP); bladder voiding pressure, any technique] has also been reported.

Q We’re seeing more and more patients who are obese. Because of their habitus, we are unable to evaluate the uterus and ovaries adequately at the time of the well-woman or diagnostic examination. In such cases, we’ve begun ordering transvaginal ultrasonography (US). Our billing staff reports that most of these claims are being denied for lack of medical necessity. Any suggestions?

A This is a dilemma, to be sure—one where the payer has the deciding voice over what is and what isn’t medically indicated. An option is to report a diagnosis of obesity linked to the US scan, along with V72.31 for a preventive exam or another diagnosis code representing the presenting problem or complaint.

If the US scan is also inconclusive, you can report 793.91 (image test inconclusive due to excess body fat) with another code that represents the patient’s documented body mass index.

Appeal the determination if the US scan is denied on the basis of medical necessity. Let the payer know that a thorough pelvic exam could not be completed because of the patient’s body mass; point out that obesity is a risk factor for cancer.

Making those points should help you get paid, eventually—although The Centers for Medicare & Medicaid Services (CMS) and most payers have determined that US as a confirmatory adjunct to physical examination (in the absence of an abnormal finding) will not be reimbursed.

Slow payment for unlisted codes for lap hysterectomy

Q My surgeon performed a total laparoscopic hysterectomy in which he removed the entire specimen through the laparoscope. Must I report an unlisted code for this procedure?

A No. You have the option instead of reporting one of the codes for a laparoscopic vaginal hysterectomy (codes 58550–58554) because the vaginal part is only for retrieving the specimen, which is otherwise released from its attachment through the laparoscope. This is the recommendation of ACOG and the American Association of Gynecologic Laparoscopists (AAGL).

(There is good news here: New codes for total laparoscopic hysterectomy will be available beginning January 1, 2008. Look for details on these and other changes in Reimbursement Adviser in the December 2007 issue of OBG Management.)

Of course, your other coding option is to report the unlisted code 58578 (un-listed laparoscopic procedure, uterus). If you choose that option, however, you will have to submit the operative report with the claim, along with a letter from the physician explaining why this procedure was more advantageous to the patient than LAVH. And although using an unlisted code will not mean denial of service, it will slow down payment.

No need for modifiers on self-performed US scans

Q Our four-physician OB practice performs limited US scans on our pregnant patients. The only code we use is 76815. The practice owns the US machine and all four of us perform the scans, print the photographs, and create reports from the machine ourselves. Should we be billing these scans with modifier -26?

A No. Modifier -26 is only reported when the global service is not provided—that is, when you do not own the US machine. The unmodified code 76815 represents the technical and professional components of the US procedure, so you are coding correctly by not adding a modifier.

Although you are acting as your own sonographer for your scans, this still represents the technical component of a scan, which is reimbursed when reporting the unmodified code for the service.

It’s “false labor” if there’s no bleeding—at any date

Q My pregnant patient who delivered her previous pregnancy at 28 weeks because of premature labor is now complaining of contractions at 20.3 weeks. Would 640.03 (threatened abortion; antepartum condition or complication) be the appropriate code even though she is not bleeding?

A Twenty weeks is very early to deliver, but you would have to report 644.13 (other threatened labor) because it is the default code for false labor regardless of gestational weeks, according to a staff member of the ICD-9-CM Coordination and Maintenance Committee. A hemorrhage code, such as 640.03, should not be reported in the absence of documented bleeding. If contractions progress, however, move on to the next code that matches the situation.

Colporrhaphy? Do not code for posterior repair

Q We have been told that we can report code 45560 (repair of rectocele [separate procedure]) for posterior repair of a rectocele. I’ve noted that the relative value units (RVUs) for this procedure are higher than for a posterior colporrhaphy. Please clarify: When is it appropriate to bill 45560?

A The simple answer is that you must bill the procedure that you’ve documented, and colporrhaphy is the procedure performed by 99% of ObGyns to repair a rectocele. Typically, this involves making a midline incision in the posterior vaginal wall, plicating rectovaginal tissue, suturing it together, cutting off excess tissue, and, sometimes, supporting weakened rectovaginal tissue with mesh.

The code 45560, on the other hand, is listed in the digestive section of CPT and is, basically, a transanal approach procedure that has a vaginal component. It is much different than posterior colporrhaphy, and is typically performed when a patient with a rectocele has fecal incontinence.

Although 45560 does carry slightly more RVUs than 57250 (posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), the physician work portion of the RVU total for both codes is now identical: 11.42.

Last, be aware: Payers consider it fraud for a surgeon to use the wrong code in this situation because it pays more, when, in fact, colporrhaphy has been performed and documented.

Patient asks for test; is that “medical necessity”?

Q Occasionally, we see a patient with a family history of ovarian cancer who requests a test for cancer antigen 125. If the result is elevated and we decide to perform a US scan, what diagnosis code should we add for medical necessity? Our experience using a family history code with payers has not been good.

A The correct primary diagnosis code for this situation is 795.82 (elevated cancer antigen 125), followed by V16.41 (family history of malignant neoplasm; genital organs; ovary).

Q We’re seeing more and more patients who are obese. Because of their habitus, we are unable to evaluate the uterus and ovaries adequately at the time of the well-woman or diagnostic examination. In such cases, we’ve begun ordering transvaginal ultrasonography (US). Our billing staff reports that most of these claims are being denied for lack of medical necessity. Any suggestions?

A This is a dilemma, to be sure—one where the payer has the deciding voice over what is and what isn’t medically indicated. An option is to report a diagnosis of obesity linked to the US scan, along with V72.31 for a preventive exam or another diagnosis code representing the presenting problem or complaint.

If the US scan is also inconclusive, you can report 793.91 (image test inconclusive due to excess body fat) with another code that represents the patient’s documented body mass index.

Appeal the determination if the US scan is denied on the basis of medical necessity. Let the payer know that a thorough pelvic exam could not be completed because of the patient’s body mass; point out that obesity is a risk factor for cancer.

Making those points should help you get paid, eventually—although The Centers for Medicare & Medicaid Services (CMS) and most payers have determined that US as a confirmatory adjunct to physical examination (in the absence of an abnormal finding) will not be reimbursed.

Slow payment for unlisted codes for lap hysterectomy

Q My surgeon performed a total laparoscopic hysterectomy in which he removed the entire specimen through the laparoscope. Must I report an unlisted code for this procedure?

A No. You have the option instead of reporting one of the codes for a laparoscopic vaginal hysterectomy (codes 58550–58554) because the vaginal part is only for retrieving the specimen, which is otherwise released from its attachment through the laparoscope. This is the recommendation of ACOG and the American Association of Gynecologic Laparoscopists (AAGL).

(There is good news here: New codes for total laparoscopic hysterectomy will be available beginning January 1, 2008. Look for details on these and other changes in Reimbursement Adviser in the December 2007 issue of OBG Management.)

Of course, your other coding option is to report the unlisted code 58578 (un-listed laparoscopic procedure, uterus). If you choose that option, however, you will have to submit the operative report with the claim, along with a letter from the physician explaining why this procedure was more advantageous to the patient than LAVH. And although using an unlisted code will not mean denial of service, it will slow down payment.

No need for modifiers on self-performed US scans

Q Our four-physician OB practice performs limited US scans on our pregnant patients. The only code we use is 76815. The practice owns the US machine and all four of us perform the scans, print the photographs, and create reports from the machine ourselves. Should we be billing these scans with modifier -26?

A No. Modifier -26 is only reported when the global service is not provided—that is, when you do not own the US machine. The unmodified code 76815 represents the technical and professional components of the US procedure, so you are coding correctly by not adding a modifier.

Although you are acting as your own sonographer for your scans, this still represents the technical component of a scan, which is reimbursed when reporting the unmodified code for the service.

It’s “false labor” if there’s no bleeding—at any date

Q My pregnant patient who delivered her previous pregnancy at 28 weeks because of premature labor is now complaining of contractions at 20.3 weeks. Would 640.03 (threatened abortion; antepartum condition or complication) be the appropriate code even though she is not bleeding?

A Twenty weeks is very early to deliver, but you would have to report 644.13 (other threatened labor) because it is the default code for false labor regardless of gestational weeks, according to a staff member of the ICD-9-CM Coordination and Maintenance Committee. A hemorrhage code, such as 640.03, should not be reported in the absence of documented bleeding. If contractions progress, however, move on to the next code that matches the situation.

Colporrhaphy? Do not code for posterior repair

Q We have been told that we can report code 45560 (repair of rectocele [separate procedure]) for posterior repair of a rectocele. I’ve noted that the relative value units (RVUs) for this procedure are higher than for a posterior colporrhaphy. Please clarify: When is it appropriate to bill 45560?

A The simple answer is that you must bill the procedure that you’ve documented, and colporrhaphy is the procedure performed by 99% of ObGyns to repair a rectocele. Typically, this involves making a midline incision in the posterior vaginal wall, plicating rectovaginal tissue, suturing it together, cutting off excess tissue, and, sometimes, supporting weakened rectovaginal tissue with mesh.

The code 45560, on the other hand, is listed in the digestive section of CPT and is, basically, a transanal approach procedure that has a vaginal component. It is much different than posterior colporrhaphy, and is typically performed when a patient with a rectocele has fecal incontinence.

Although 45560 does carry slightly more RVUs than 57250 (posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), the physician work portion of the RVU total for both codes is now identical: 11.42.

Last, be aware: Payers consider it fraud for a surgeon to use the wrong code in this situation because it pays more, when, in fact, colporrhaphy has been performed and documented.

Patient asks for test; is that “medical necessity”?

Q Occasionally, we see a patient with a family history of ovarian cancer who requests a test for cancer antigen 125. If the result is elevated and we decide to perform a US scan, what diagnosis code should we add for medical necessity? Our experience using a family history code with payers has not been good.

A The correct primary diagnosis code for this situation is 795.82 (elevated cancer antigen 125), followed by V16.41 (family history of malignant neoplasm; genital organs; ovary).

Q We’re seeing more and more patients who are obese. Because of their habitus, we are unable to evaluate the uterus and ovaries adequately at the time of the well-woman or diagnostic examination. In such cases, we’ve begun ordering transvaginal ultrasonography (US). Our billing staff reports that most of these claims are being denied for lack of medical necessity. Any suggestions?

A This is a dilemma, to be sure—one where the payer has the deciding voice over what is and what isn’t medically indicated. An option is to report a diagnosis of obesity linked to the US scan, along with V72.31 for a preventive exam or another diagnosis code representing the presenting problem or complaint.

If the US scan is also inconclusive, you can report 793.91 (image test inconclusive due to excess body fat) with another code that represents the patient’s documented body mass index.

Appeal the determination if the US scan is denied on the basis of medical necessity. Let the payer know that a thorough pelvic exam could not be completed because of the patient’s body mass; point out that obesity is a risk factor for cancer.

Making those points should help you get paid, eventually—although The Centers for Medicare & Medicaid Services (CMS) and most payers have determined that US as a confirmatory adjunct to physical examination (in the absence of an abnormal finding) will not be reimbursed.

Slow payment for unlisted codes for lap hysterectomy

Q My surgeon performed a total laparoscopic hysterectomy in which he removed the entire specimen through the laparoscope. Must I report an unlisted code for this procedure?

A No. You have the option instead of reporting one of the codes for a laparoscopic vaginal hysterectomy (codes 58550–58554) because the vaginal part is only for retrieving the specimen, which is otherwise released from its attachment through the laparoscope. This is the recommendation of ACOG and the American Association of Gynecologic Laparoscopists (AAGL).

(There is good news here: New codes for total laparoscopic hysterectomy will be available beginning January 1, 2008. Look for details on these and other changes in Reimbursement Adviser in the December 2007 issue of OBG Management.)

Of course, your other coding option is to report the unlisted code 58578 (un-listed laparoscopic procedure, uterus). If you choose that option, however, you will have to submit the operative report with the claim, along with a letter from the physician explaining why this procedure was more advantageous to the patient than LAVH. And although using an unlisted code will not mean denial of service, it will slow down payment.

No need for modifiers on self-performed US scans

Q Our four-physician OB practice performs limited US scans on our pregnant patients. The only code we use is 76815. The practice owns the US machine and all four of us perform the scans, print the photographs, and create reports from the machine ourselves. Should we be billing these scans with modifier -26?

A No. Modifier -26 is only reported when the global service is not provided—that is, when you do not own the US machine. The unmodified code 76815 represents the technical and professional components of the US procedure, so you are coding correctly by not adding a modifier.

Although you are acting as your own sonographer for your scans, this still represents the technical component of a scan, which is reimbursed when reporting the unmodified code for the service.

It’s “false labor” if there’s no bleeding—at any date

Q My pregnant patient who delivered her previous pregnancy at 28 weeks because of premature labor is now complaining of contractions at 20.3 weeks. Would 640.03 (threatened abortion; antepartum condition or complication) be the appropriate code even though she is not bleeding?

A Twenty weeks is very early to deliver, but you would have to report 644.13 (other threatened labor) because it is the default code for false labor regardless of gestational weeks, according to a staff member of the ICD-9-CM Coordination and Maintenance Committee. A hemorrhage code, such as 640.03, should not be reported in the absence of documented bleeding. If contractions progress, however, move on to the next code that matches the situation.

Colporrhaphy? Do not code for posterior repair

Q We have been told that we can report code 45560 (repair of rectocele [separate procedure]) for posterior repair of a rectocele. I’ve noted that the relative value units (RVUs) for this procedure are higher than for a posterior colporrhaphy. Please clarify: When is it appropriate to bill 45560?

A The simple answer is that you must bill the procedure that you’ve documented, and colporrhaphy is the procedure performed by 99% of ObGyns to repair a rectocele. Typically, this involves making a midline incision in the posterior vaginal wall, plicating rectovaginal tissue, suturing it together, cutting off excess tissue, and, sometimes, supporting weakened rectovaginal tissue with mesh.

The code 45560, on the other hand, is listed in the digestive section of CPT and is, basically, a transanal approach procedure that has a vaginal component. It is much different than posterior colporrhaphy, and is typically performed when a patient with a rectocele has fecal incontinence.

Although 45560 does carry slightly more RVUs than 57250 (posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), the physician work portion of the RVU total for both codes is now identical: 11.42.

Last, be aware: Payers consider it fraud for a surgeon to use the wrong code in this situation because it pays more, when, in fact, colporrhaphy has been performed and documented.

Patient asks for test; is that “medical necessity”?

Q Occasionally, we see a patient with a family history of ovarian cancer who requests a test for cancer antigen 125. If the result is elevated and we decide to perform a US scan, what diagnosis code should we add for medical necessity? Our experience using a family history code with payers has not been good.

A The correct primary diagnosis code for this situation is 795.82 (elevated cancer antigen 125), followed by V16.41 (family history of malignant neoplasm; genital organs; ovary).