Reimbursement Advisor

Save the date! Important ObGyn revisions to the International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) take effect October 1. Take note of these additions and modifications to ensure that you’re maximizing your reimbursement on claims.

Vaginal, vulvar conditions: Simpler reporting

This year’s additions include codes for vaginal intraepithelial neoplasia (VAIN) and expansion of the vulvar intraepithelial neoplasia (VIN) category to match.

624.01	Vulvar intraepithelial neoplasia I [VIN I]
	Mild dysplasia of vulva
624.02	Vulvar intraepithelial neoplasia II [VIN II]
	Moderate dysplasia of vulva
624.09	Other dystrophy of vulva
	Kraurosis of vulva
	Leukoplakia of vulva
233.30	Unspecified female genital organ
233.31	Vagina
	Severe dysplasia of vagina
	Vaginal intraepithelial neoplasia III [VAIN III]
233.32	Vulva
	Severe dysplasia of vulva
	Vulvar intraepithelial neoplasia III [VIN III]
233.39	Other female genital organ

Until now, you have had only three codes to work with: 623.0 [dysplasia of vagina]; 624.0 [dystrophy of vulva]; and 233.3 [Ca in situ of other and unspecified genital organs]. Pathology reports often support higher specificity of coding, however, which makes it easier to establish medical necessity for further diagnostic testing or surgical intervention. Beginning October 1, the new codes specify the severity of dysplasia, so you will need to be more exact about the patient’s condition. In addition, 623.0, the established code for vaginal dysplasia, now specifically references both VAIN I and II.

An “excludes” note has also been added to 622.1 [dysplasia of cervix (uteri)] to clarify that a diagnosis of carcinoma in situ I or II may not be reported unless this diagnosis is assigned based on a biopsy finding—not on an abnormal finding on a Pap smear.

New code for trauma during delivery

Anal sphincter tears can occur during delivery without an accompanying third-degree perineal laceration, so a new code [664.6X, anal sphincter tear complicating delivery, not associated with third-degree perineal laceration] has been added to capture this information. Keep in mind these important points:

• Report the new code when an anal tear is noted at or after delivery. The only acceptable fifth digits for this code are 0 [unspecified as to episode of care or not applicable], 1 [delivered, with or without mention of antepartum condition], or 4 [postpartum condition or complication].
  
• Report the established code, 664.2X [third-degree perineal laceration] if an anal tear is noted in addition to a third-degree perineal tear. The fifth digit will be 0, 1, or 4, as it is with the code for an anal sphincter tear.
  
• Report the established code 654.8X [congenital or acquired abnormality of vulva] if the patient had an anal tear from a prior pregnancy, before the current delivery.
  
• Last, report the new code 569.43 [anal sphincter tear (healed) (old)] if you observe that the patient has an old anal tear but isn’t pregnant. Report an additional code for any associated fecal incontinence (787.6).
  

Anal tears can complicate the next delivery and are responsible for fecal incontinence—a finding that may lead to a diagnosis of an old, unhealed anal sphincter tear. Remember that, for this coming year, you have to document the circumstance to report the correct code.

Report dysplasia follow-up as “medical necessity”

Once a patient has been treated for cervical dysplasia, long-term follow-up care is required to test for recurrence. The only code available to report that history last year was V13.29, a general code that reported all types of genital systems and obstetric disorders. This year, you can specify and report V13.22 [personal history of cervical dysplasia].

The role of human papillomavirus (HPV) as the cause of cervical cancer is well known, and routine screening tests for this infection are generally as accurate as a routine Pap smear. Because of this, a new code, V73.81 [human papillomavirus (HPV)], has been added to document encounters for HPV screening. The new code can be reported in conjunction with the routine gyn exam code, V72.31, or V76.2 [special screening for malignant neoplasm of cervix] to signal that additional screening is planned.

Better documentation of malignant ascites

789.51  Malignant ascites

789.59  Other ascites

Malignant ascites is seen most often in ovarian, endometrial, breast, colon, gastric, and pancreatic cancer. Management of this condition may include systemic chemotherapy, instillation of radioisotopes or chemotherapy drugs into peritoneal fluid, and peritoneal–venous shunting procedures.

Before October 1, under ICD-9 rules, malignant ascites could be reported only using the code 197.6 [secondary malignant neoplasm of retroperitoneum and peritoneum].The problem is that this condition can also be caused by a primary ovarian malignancy, for which there has been no reporting mechanism. With expansion of the code 789.5 [ascites], you can specify the type of malignant ascites.

 

Note: Instructions in ICD-9 indicate that you should list a code for the site of the current malignancy first, such as 183.0 [malignant neoplasm of ovary] or 197.6 [secondary malignant neoplasm of retroperitoneum and peritoneum].

Assisted reproductive fertility procedure status

Every endocrinologist is aware that assisted reproductive fertility procedures are a multistage undertaking. A number of pretreatment diagnostic tests are independent of the procedure itself, and payers might cover such tests if there were a way to identify patients who were undergoing a procedure from those who were still undergoing pretreatment testing.

Before October 1, only one code, V26.8 [other specified procreative management], was available. Starting this month, to identify a patient undergoing treatment, use V26.81 [encounter for assisted reproductive fertility procedure cycle], with an additional code to identify the type of infertility. With this expansion, a second code was added to capture “other specified procreative management” [V26.89].

Natural family planning comes of age

Natural family planning helps a couple determine when sexual intercourse is likely to (and not likely to) result in pregnancy. It encompasses provider counseling and education on either of two acceptable methods: tracking ovulation by examining cervical mucus or temperature charting. ICD-9 has expanded the existing code, V26.4, to capture this means of family planning more accurately:

V26.41  Procreative counseling and advice using natural family planning

In addition, a code was added to the contraceptive counseling codes to capture this approach as well:

V25.04  Counseling and instruction in natural family planning to avoid pregnancy

Last, a new code also covers other types of procreative management counseling and advice:

V26.49  Other procreative management counseling and advice

Disability certificates, made easy(ier) to report

Do patients come to you to have medical forms and certificates completed? Now you can be more specific, when coding, about the type of document you’re asked to fill out.

V68.01  Disability examination

V68.09  Other issue of medical certificates

The old code, V68.0, was a catch-all of medical certificates, including cause of death, fitness, and disability. The new codes distinguish a certificate for a disability examination from the rest of the pack. That’s a useful change because insurers and state disability programs often reimburse for a disability exam.

Remember: You still need to identify the specific exam, screening, or testing performed by using a code from the series V72.0–V82.9 as a secondary diagnosis. Examples: V72.31 for a gyn exam and V81.6 [screening for other and unspecified genitourinary conditions].

Diversified codes for iatrogenic ID complications

Patients sometimes develop infection in the presence of a central venous catheter or after injection or vaccination. Previously, you used code 999.3 to report such a complication, but that code lumped into one all reasons for infection.

This year, a new code, 993.31, exclusively covers infection caused by a central venous catheter. The code lists several catheter types—Hickman, peripherally inserted central catheter (PICC), triplelumen catheter—and makes clear that it should not be used to report infection caused by a urinary (996.64), arterial (996.62), venous (996.62), or unspecified type of catheter (996.69).

An additional code, 999.39, has been added to report all infections after intravenous infusion, injection, transfusion, or vaccination.

Save the date! Important ObGyn revisions to the International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) take effect October 1. Take note of these additions and modifications to ensure that you’re maximizing your reimbursement on claims.

Vaginal, vulvar conditions: Simpler reporting

This year’s additions include codes for vaginal intraepithelial neoplasia (VAIN) and expansion of the vulvar intraepithelial neoplasia (VIN) category to match.

624.01	Vulvar intraepithelial neoplasia I [VIN I]
	Mild dysplasia of vulva
624.02	Vulvar intraepithelial neoplasia II [VIN II]
	Moderate dysplasia of vulva
624.09	Other dystrophy of vulva
	Kraurosis of vulva
	Leukoplakia of vulva
233.30	Unspecified female genital organ
233.31	Vagina
	Severe dysplasia of vagina
	Vaginal intraepithelial neoplasia III [VAIN III]
233.32	Vulva
	Severe dysplasia of vulva
	Vulvar intraepithelial neoplasia III [VIN III]
233.39	Other female genital organ

Until now, you have had only three codes to work with: 623.0 [dysplasia of vagina]; 624.0 [dystrophy of vulva]; and 233.3 [Ca in situ of other and unspecified genital organs]. Pathology reports often support higher specificity of coding, however, which makes it easier to establish medical necessity for further diagnostic testing or surgical intervention. Beginning October 1, the new codes specify the severity of dysplasia, so you will need to be more exact about the patient’s condition. In addition, 623.0, the established code for vaginal dysplasia, now specifically references both VAIN I and II.

An “excludes” note has also been added to 622.1 [dysplasia of cervix (uteri)] to clarify that a diagnosis of carcinoma in situ I or II may not be reported unless this diagnosis is assigned based on a biopsy finding—not on an abnormal finding on a Pap smear.

New code for trauma during delivery

Anal sphincter tears can occur during delivery without an accompanying third-degree perineal laceration, so a new code [664.6X, anal sphincter tear complicating delivery, not associated with third-degree perineal laceration] has been added to capture this information. Keep in mind these important points:

• Report the new code when an anal tear is noted at or after delivery. The only acceptable fifth digits for this code are 0 [unspecified as to episode of care or not applicable], 1 [delivered, with or without mention of antepartum condition], or 4 [postpartum condition or complication].
  
• Report the established code, 664.2X [third-degree perineal laceration] if an anal tear is noted in addition to a third-degree perineal tear. The fifth digit will be 0, 1, or 4, as it is with the code for an anal sphincter tear.
  
• Report the established code 654.8X [congenital or acquired abnormality of vulva] if the patient had an anal tear from a prior pregnancy, before the current delivery.
  
• Last, report the new code 569.43 [anal sphincter tear (healed) (old)] if you observe that the patient has an old anal tear but isn’t pregnant. Report an additional code for any associated fecal incontinence (787.6).
  

Anal tears can complicate the next delivery and are responsible for fecal incontinence—a finding that may lead to a diagnosis of an old, unhealed anal sphincter tear. Remember that, for this coming year, you have to document the circumstance to report the correct code.

Report dysplasia follow-up as “medical necessity”

Once a patient has been treated for cervical dysplasia, long-term follow-up care is required to test for recurrence. The only code available to report that history last year was V13.29, a general code that reported all types of genital systems and obstetric disorders. This year, you can specify and report V13.22 [personal history of cervical dysplasia].

The role of human papillomavirus (HPV) as the cause of cervical cancer is well known, and routine screening tests for this infection are generally as accurate as a routine Pap smear. Because of this, a new code, V73.81 [human papillomavirus (HPV)], has been added to document encounters for HPV screening. The new code can be reported in conjunction with the routine gyn exam code, V72.31, or V76.2 [special screening for malignant neoplasm of cervix] to signal that additional screening is planned.

Better documentation of malignant ascites

789.51  Malignant ascites

789.59  Other ascites

Malignant ascites is seen most often in ovarian, endometrial, breast, colon, gastric, and pancreatic cancer. Management of this condition may include systemic chemotherapy, instillation of radioisotopes or chemotherapy drugs into peritoneal fluid, and peritoneal–venous shunting procedures.

Before October 1, under ICD-9 rules, malignant ascites could be reported only using the code 197.6 [secondary malignant neoplasm of retroperitoneum and peritoneum].The problem is that this condition can also be caused by a primary ovarian malignancy, for which there has been no reporting mechanism. With expansion of the code 789.5 [ascites], you can specify the type of malignant ascites.

 

Note: Instructions in ICD-9 indicate that you should list a code for the site of the current malignancy first, such as 183.0 [malignant neoplasm of ovary] or 197.6 [secondary malignant neoplasm of retroperitoneum and peritoneum].

Assisted reproductive fertility procedure status

Every endocrinologist is aware that assisted reproductive fertility procedures are a multistage undertaking. A number of pretreatment diagnostic tests are independent of the procedure itself, and payers might cover such tests if there were a way to identify patients who were undergoing a procedure from those who were still undergoing pretreatment testing.

Before October 1, only one code, V26.8 [other specified procreative management], was available. Starting this month, to identify a patient undergoing treatment, use V26.81 [encounter for assisted reproductive fertility procedure cycle], with an additional code to identify the type of infertility. With this expansion, a second code was added to capture “other specified procreative management” [V26.89].

Natural family planning comes of age

Natural family planning helps a couple determine when sexual intercourse is likely to (and not likely to) result in pregnancy. It encompasses provider counseling and education on either of two acceptable methods: tracking ovulation by examining cervical mucus or temperature charting. ICD-9 has expanded the existing code, V26.4, to capture this means of family planning more accurately:

V26.41  Procreative counseling and advice using natural family planning

In addition, a code was added to the contraceptive counseling codes to capture this approach as well:

V25.04  Counseling and instruction in natural family planning to avoid pregnancy

Last, a new code also covers other types of procreative management counseling and advice:

V26.49  Other procreative management counseling and advice

Disability certificates, made easy(ier) to report

Do patients come to you to have medical forms and certificates completed? Now you can be more specific, when coding, about the type of document you’re asked to fill out.

V68.01  Disability examination

V68.09  Other issue of medical certificates

The old code, V68.0, was a catch-all of medical certificates, including cause of death, fitness, and disability. The new codes distinguish a certificate for a disability examination from the rest of the pack. That’s a useful change because insurers and state disability programs often reimburse for a disability exam.

Remember: You still need to identify the specific exam, screening, or testing performed by using a code from the series V72.0–V82.9 as a secondary diagnosis. Examples: V72.31 for a gyn exam and V81.6 [screening for other and unspecified genitourinary conditions].

Diversified codes for iatrogenic ID complications

Patients sometimes develop infection in the presence of a central venous catheter or after injection or vaccination. Previously, you used code 999.3 to report such a complication, but that code lumped into one all reasons for infection.

This year, a new code, 993.31, exclusively covers infection caused by a central venous catheter. The code lists several catheter types—Hickman, peripherally inserted central catheter (PICC), triplelumen catheter—and makes clear that it should not be used to report infection caused by a urinary (996.64), arterial (996.62), venous (996.62), or unspecified type of catheter (996.69).

An additional code, 999.39, has been added to report all infections after intravenous infusion, injection, transfusion, or vaccination.

Save the date! Important ObGyn revisions to the International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) take effect October 1. Take note of these additions and modifications to ensure that you’re maximizing your reimbursement on claims.

Vaginal, vulvar conditions: Simpler reporting

This year’s additions include codes for vaginal intraepithelial neoplasia (VAIN) and expansion of the vulvar intraepithelial neoplasia (VIN) category to match.

624.01	Vulvar intraepithelial neoplasia I [VIN I]
	Mild dysplasia of vulva
624.02	Vulvar intraepithelial neoplasia II [VIN II]
	Moderate dysplasia of vulva
624.09	Other dystrophy of vulva
	Kraurosis of vulva
	Leukoplakia of vulva
233.30	Unspecified female genital organ
233.31	Vagina
	Severe dysplasia of vagina
	Vaginal intraepithelial neoplasia III [VAIN III]
233.32	Vulva
	Severe dysplasia of vulva
	Vulvar intraepithelial neoplasia III [VIN III]
233.39	Other female genital organ

Until now, you have had only three codes to work with: 623.0 [dysplasia of vagina]; 624.0 [dystrophy of vulva]; and 233.3 [Ca in situ of other and unspecified genital organs]. Pathology reports often support higher specificity of coding, however, which makes it easier to establish medical necessity for further diagnostic testing or surgical intervention. Beginning October 1, the new codes specify the severity of dysplasia, so you will need to be more exact about the patient’s condition. In addition, 623.0, the established code for vaginal dysplasia, now specifically references both VAIN I and II.

An “excludes” note has also been added to 622.1 [dysplasia of cervix (uteri)] to clarify that a diagnosis of carcinoma in situ I or II may not be reported unless this diagnosis is assigned based on a biopsy finding—not on an abnormal finding on a Pap smear.

New code for trauma during delivery

Anal sphincter tears can occur during delivery without an accompanying third-degree perineal laceration, so a new code [664.6X, anal sphincter tear complicating delivery, not associated with third-degree perineal laceration] has been added to capture this information. Keep in mind these important points:

• Report the new code when an anal tear is noted at or after delivery. The only acceptable fifth digits for this code are 0 [unspecified as to episode of care or not applicable], 1 [delivered, with or without mention of antepartum condition], or 4 [postpartum condition or complication].
  
• Report the established code, 664.2X [third-degree perineal laceration] if an anal tear is noted in addition to a third-degree perineal tear. The fifth digit will be 0, 1, or 4, as it is with the code for an anal sphincter tear.
  
• Report the established code 654.8X [congenital or acquired abnormality of vulva] if the patient had an anal tear from a prior pregnancy, before the current delivery.
  
• Last, report the new code 569.43 [anal sphincter tear (healed) (old)] if you observe that the patient has an old anal tear but isn’t pregnant. Report an additional code for any associated fecal incontinence (787.6).
  

Anal tears can complicate the next delivery and are responsible for fecal incontinence—a finding that may lead to a diagnosis of an old, unhealed anal sphincter tear. Remember that, for this coming year, you have to document the circumstance to report the correct code.

Report dysplasia follow-up as “medical necessity”

Once a patient has been treated for cervical dysplasia, long-term follow-up care is required to test for recurrence. The only code available to report that history last year was V13.29, a general code that reported all types of genital systems and obstetric disorders. This year, you can specify and report V13.22 [personal history of cervical dysplasia].

The role of human papillomavirus (HPV) as the cause of cervical cancer is well known, and routine screening tests for this infection are generally as accurate as a routine Pap smear. Because of this, a new code, V73.81 [human papillomavirus (HPV)], has been added to document encounters for HPV screening. The new code can be reported in conjunction with the routine gyn exam code, V72.31, or V76.2 [special screening for malignant neoplasm of cervix] to signal that additional screening is planned.

Better documentation of malignant ascites

789.51  Malignant ascites

789.59  Other ascites

Malignant ascites is seen most often in ovarian, endometrial, breast, colon, gastric, and pancreatic cancer. Management of this condition may include systemic chemotherapy, instillation of radioisotopes or chemotherapy drugs into peritoneal fluid, and peritoneal–venous shunting procedures.

Before October 1, under ICD-9 rules, malignant ascites could be reported only using the code 197.6 [secondary malignant neoplasm of retroperitoneum and peritoneum].The problem is that this condition can also be caused by a primary ovarian malignancy, for which there has been no reporting mechanism. With expansion of the code 789.5 [ascites], you can specify the type of malignant ascites.

 

Note: Instructions in ICD-9 indicate that you should list a code for the site of the current malignancy first, such as 183.0 [malignant neoplasm of ovary] or 197.6 [secondary malignant neoplasm of retroperitoneum and peritoneum].

Assisted reproductive fertility procedure status

Every endocrinologist is aware that assisted reproductive fertility procedures are a multistage undertaking. A number of pretreatment diagnostic tests are independent of the procedure itself, and payers might cover such tests if there were a way to identify patients who were undergoing a procedure from those who were still undergoing pretreatment testing.

Before October 1, only one code, V26.8 [other specified procreative management], was available. Starting this month, to identify a patient undergoing treatment, use V26.81 [encounter for assisted reproductive fertility procedure cycle], with an additional code to identify the type of infertility. With this expansion, a second code was added to capture “other specified procreative management” [V26.89].

Natural family planning comes of age

Natural family planning helps a couple determine when sexual intercourse is likely to (and not likely to) result in pregnancy. It encompasses provider counseling and education on either of two acceptable methods: tracking ovulation by examining cervical mucus or temperature charting. ICD-9 has expanded the existing code, V26.4, to capture this means of family planning more accurately:

V26.41  Procreative counseling and advice using natural family planning

In addition, a code was added to the contraceptive counseling codes to capture this approach as well:

V25.04  Counseling and instruction in natural family planning to avoid pregnancy

Last, a new code also covers other types of procreative management counseling and advice:

V26.49  Other procreative management counseling and advice

Disability certificates, made easy(ier) to report

Do patients come to you to have medical forms and certificates completed? Now you can be more specific, when coding, about the type of document you’re asked to fill out.

V68.01  Disability examination

V68.09  Other issue of medical certificates

The old code, V68.0, was a catch-all of medical certificates, including cause of death, fitness, and disability. The new codes distinguish a certificate for a disability examination from the rest of the pack. That’s a useful change because insurers and state disability programs often reimburse for a disability exam.

Remember: You still need to identify the specific exam, screening, or testing performed by using a code from the series V72.0–V82.9 as a secondary diagnosis. Examples: V72.31 for a gyn exam and V81.6 [screening for other and unspecified genitourinary conditions].

Diversified codes for iatrogenic ID complications

Patients sometimes develop infection in the presence of a central venous catheter or after injection or vaccination. Previously, you used code 999.3 to report such a complication, but that code lumped into one all reasons for infection.

This year, a new code, 993.31, exclusively covers infection caused by a central venous catheter. The code lists several catheter types—Hickman, peripherally inserted central catheter (PICC), triplelumen catheter—and makes clear that it should not be used to report infection caused by a urinary (996.64), arterial (996.62), venous (996.62), or unspecified type of catheter (996.69).

An additional code, 999.39, has been added to report all infections after intravenous infusion, injection, transfusion, or vaccination.

The Centers for Medicare and Medicaid Services (CMS) launched its Physician Quality Reporting Initiative (PQRI) July 1. This program, voluntary in 2007, rewards physicians for reporting a designated set of quality measures. Physicians who successfully report these measures under established criteria earn a bonus payment, subject to a cap, of 1.5% of their total allowed charges for covered services paid under the Medicare physician fee schedule.

Quality measures are reported on the CMS claim form just as any other service would be, except that no charge is billed for the reported measure. The time frame established for the reporting of these measures is July 1 through December 31 of this year. Although there are plans to continue the program in 2008, it is unclear whether funds will be available for a bonus in 2009, and the measures for 2008 will be different from those used in 2007.

To calculate the potential bonus amount when at least 3 measures are successfully reported, use your total Medicare income for the past 6 months. If you received $60,000 for treating Medicare patients from January 1 through May 31, for example, and Medicare income has been steady, expect a lump sum bonus of $900 in mid-2008.

How do I report an intervention?

Good news: You do not have to register to participate in PQRI; you need only report the selected quality measures each time you submit a claim for the patient service to which the quality measure applies. Criteria for reporting (and then receiving the bonus in mid-2008) for these quality measures are as follows:

• Select the quality measures that apply most often to your practice (see the TABLE)
  
• Enter the PQRI codes on block 24D of the CMS 1500 claim form with a $0.00 dollar amount; if your system does not allow this amount to be entered, change it to $0.01
  
• There must be a match between the acceptable CPT or ICD-9 code reported for the overall service with a CPT Category II or HCPCS “G” code designated as the quality measure, as listed in the Medicare specifications file (www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage)
  
• Apply any applicable allowed modifier that explains why the quality measure was not assessed:
  

The measure specifications are organized to provide specific information:

• Measure title
  
• Description
  
• Instructions on reporting, including frequency, time frames, and applicability
  
• Numerator coding
  
• Definition of terms
  
• Coding instructions
  

For example: Measure 48 documents the percentage of female patients age 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months. The denominator for this measure is represented by the reported evaluation and management (E/M) service approved for this measure (ie, 99201–99205 [new patient E/M service], 99212–99215 [established patient E/M service], 99241– 99245 [outpatient consultation], 99387 [preventive new patient service], 99397 [preventive established patient service], 99401–99404 [preventive counseling visits]), along with the information on the claim that indicates the patient’s age and sex.

The numerator part of the measure is represented by a CPT Category II code with or without a modifier. CPT code 1090F (presence or absence of urinary stress incontinence assessed) would be reported if the presence or absence of urinary incontinence was assessed, but a modifier 1P is placed in box 24E of the claim form if you have documented a medical reason why this was not assessed, or modifier 8P if it was not assessed but the reason was not documented.

TABLE

The Physician Quality Reporting Initiative: 10 measures may apply to ObGyn practice in 2007

MEASURE	CONSTRAINTS AND COMMENTS
#20 Perioperative care: Timing of antibiotic prophylaxis—ordering physician	Documentation in medical record that drug was ordered or given 1–2 hours prior to surgery CPT codes applicable to gyn surgery: 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4047F or 4048F Allowed modifiers: 1P and 8P
#21 Perioperative care: Selection of prophylactic antibiotic—first- or second-generation cephalosporin	Documentation in medical record that cefazolin or cefuroxime was ordered or given CPT codes applicable to gyn surgery: 49000, 49002, 49010, 49180, 49200, 49201, 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4041F Allowed modifiers: 1P and 8P
#22 Perioperative care: Discontinuation of prophylactic antibiotic (non-cardiac procedures)	Documentation of an order for or evidence of discontinuation of prophylactic antibiotics within 24 hours of surgical end time, or specification of an antibiotic to be given in doses within that 24-hour period CPT codes applicable to gyn surgery: 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4049F and 4946F Allowed modifiers: 1P and 8P
#23 Perioperative care: venous thromboembolism prophylaxis (when indicated in all patients)	Documentation in medical record of an order for low-molecular-weight heparin, low-dose unfractionated heparin, adjusted-dose warfarin, fondaparinux, or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time CPT codes applicable to gyn surgery: 49000, 49002, 49010, 49020, 49040, 49060, 49200, 49201, 56630, 56631, 56632, 56633, 56634, 56637, 56640, 58200, 58210, 58240, 58285, 58951, 58953, 58954, 58956 CPT II codes: 4044F Allowed modifiers: 1P and 8P
#39 Screening or therapy for osteoporosis for women 65 years and older	Documentation of an order for or performance of (with recorded results) a central dual-energy x-ray absorptiometry measurement performed at least once since age 60, or pharmacologic therapy prescribed within 12 months. Drugs include bisphosphonates, calcitonin, estrogens, parathyroid hormone, and selective estrogen receptor modulators Applicable E/M codes: 99201–99205, 99212–99215, 99387, 99397, 99401–99404 CPT II codes: 3096F, 3095F, or 4005F Allowed modifiers: 1P, 2P, 3P, 8P
#41 Osteoporosis: Pharmacotherapy	Documentation that the patient was prescribed pharmacologic therapy within 12 months. Applicable drugs are as listed in measure #39 above. Applicable E/M codes: 99201–99205, 99212–99215, 99241, 99242, 99243, 99244, 99245, 99386–99387, 99396–99397, 99401–99404 PLUS ICD-9-CM diagnosis codes: 733.00, 733.01, 733.02, 733.03, 733.09 CPT II codes: 4005F Allowed modifiers: 1P, 2P, 3P, 8P
#42 Osteoporosis: Counseling for vitamin D and calcium intake, and exercise	Documentation that the patient either is receiving both calcium and vitamin D or has been counseled for both calcium and vitamin D intake, and exercise at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99385–99387, 99395–99397, 99401–99404 PLUS ICD-9-CM diagnosis codes: 733.00, 733.01, 733.02, 733.03, 733.09 CPT II codes: 4019F Allowed modifiers: 1P and 8P
#48 Assessment of presence or absence of urinary incontinence in women aged 65 years and older	Documentation that patient was assessed for the presence or absence of urinary incontinence within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99387, 99397, 99401–99402 CPT II codes: 1090F Allowed modifiers: 1P and 8P
#49 Characterization of urinary incontinence in women aged 65 years and older	Documentation of frequency, volume, timing, type of symptoms, and how bothersome to the patient at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99387, 99397, 99401–99402 PLUS ICD-9-CM diagnosis codes: 307.6, 625.6, 788.30, 788.31, 788.32, 788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39 CPT II codes: 1091F Allowed modifiers: 8P
#50 Plan of care for urinary incontinence in women aged 65 years and older	Documentation that a plan of care for urinary incontinence was formulated at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99387, 99397, 99401–99402 PLUS ICD-9-CM diagnosis codes: 307.6, 625.6, 788.30, 788.31, 788.32, 788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39 CPT II codes: 0509F Allowed modifiers: 8P

The Centers for Medicare and Medicaid Services (CMS) launched its Physician Quality Reporting Initiative (PQRI) July 1. This program, voluntary in 2007, rewards physicians for reporting a designated set of quality measures. Physicians who successfully report these measures under established criteria earn a bonus payment, subject to a cap, of 1.5% of their total allowed charges for covered services paid under the Medicare physician fee schedule.

Quality measures are reported on the CMS claim form just as any other service would be, except that no charge is billed for the reported measure. The time frame established for the reporting of these measures is July 1 through December 31 of this year. Although there are plans to continue the program in 2008, it is unclear whether funds will be available for a bonus in 2009, and the measures for 2008 will be different from those used in 2007.

To calculate the potential bonus amount when at least 3 measures are successfully reported, use your total Medicare income for the past 6 months. If you received $60,000 for treating Medicare patients from January 1 through May 31, for example, and Medicare income has been steady, expect a lump sum bonus of $900 in mid-2008.

How do I report an intervention?

Good news: You do not have to register to participate in PQRI; you need only report the selected quality measures each time you submit a claim for the patient service to which the quality measure applies. Criteria for reporting (and then receiving the bonus in mid-2008) for these quality measures are as follows:

• Select the quality measures that apply most often to your practice (see the TABLE)
  
• Enter the PQRI codes on block 24D of the CMS 1500 claim form with a $0.00 dollar amount; if your system does not allow this amount to be entered, change it to $0.01
  
• There must be a match between the acceptable CPT or ICD-9 code reported for the overall service with a CPT Category II or HCPCS “G” code designated as the quality measure, as listed in the Medicare specifications file (www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage)
  
• Apply any applicable allowed modifier that explains why the quality measure was not assessed:
  

The measure specifications are organized to provide specific information:

• Measure title
  
• Description
  
• Instructions on reporting, including frequency, time frames, and applicability
  
• Numerator coding
  
• Definition of terms
  
• Coding instructions
  

For example: Measure 48 documents the percentage of female patients age 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months. The denominator for this measure is represented by the reported evaluation and management (E/M) service approved for this measure (ie, 99201–99205 [new patient E/M service], 99212–99215 [established patient E/M service], 99241– 99245 [outpatient consultation], 99387 [preventive new patient service], 99397 [preventive established patient service], 99401–99404 [preventive counseling visits]), along with the information on the claim that indicates the patient’s age and sex.

The numerator part of the measure is represented by a CPT Category II code with or without a modifier. CPT code 1090F (presence or absence of urinary stress incontinence assessed) would be reported if the presence or absence of urinary incontinence was assessed, but a modifier 1P is placed in box 24E of the claim form if you have documented a medical reason why this was not assessed, or modifier 8P if it was not assessed but the reason was not documented.

TABLE

The Physician Quality Reporting Initiative: 10 measures may apply to ObGyn practice in 2007

MEASURE	CONSTRAINTS AND COMMENTS
#20 Perioperative care: Timing of antibiotic prophylaxis—ordering physician	Documentation in medical record that drug was ordered or given 1–2 hours prior to surgery CPT codes applicable to gyn surgery: 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4047F or 4048F Allowed modifiers: 1P and 8P
#21 Perioperative care: Selection of prophylactic antibiotic—first- or second-generation cephalosporin	Documentation in medical record that cefazolin or cefuroxime was ordered or given CPT codes applicable to gyn surgery: 49000, 49002, 49010, 49180, 49200, 49201, 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4041F Allowed modifiers: 1P and 8P
#22 Perioperative care: Discontinuation of prophylactic antibiotic (non-cardiac procedures)	Documentation of an order for or evidence of discontinuation of prophylactic antibiotics within 24 hours of surgical end time, or specification of an antibiotic to be given in doses within that 24-hour period CPT codes applicable to gyn surgery: 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4049F and 4946F Allowed modifiers: 1P and 8P
#23 Perioperative care: venous thromboembolism prophylaxis (when indicated in all patients)	Documentation in medical record of an order for low-molecular-weight heparin, low-dose unfractionated heparin, adjusted-dose warfarin, fondaparinux, or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time CPT codes applicable to gyn surgery: 49000, 49002, 49010, 49020, 49040, 49060, 49200, 49201, 56630, 56631, 56632, 56633, 56634, 56637, 56640, 58200, 58210, 58240, 58285, 58951, 58953, 58954, 58956 CPT II codes: 4044F Allowed modifiers: 1P and 8P
#39 Screening or therapy for osteoporosis for women 65 years and older	Documentation of an order for or performance of (with recorded results) a central dual-energy x-ray absorptiometry measurement performed at least once since age 60, or pharmacologic therapy prescribed within 12 months. Drugs include bisphosphonates, calcitonin, estrogens, parathyroid hormone, and selective estrogen receptor modulators Applicable E/M codes: 99201–99205, 99212–99215, 99387, 99397, 99401–99404 CPT II codes: 3096F, 3095F, or 4005F Allowed modifiers: 1P, 2P, 3P, 8P
#41 Osteoporosis: Pharmacotherapy	Documentation that the patient was prescribed pharmacologic therapy within 12 months. Applicable drugs are as listed in measure #39 above. Applicable E/M codes: 99201–99205, 99212–99215, 99241, 99242, 99243, 99244, 99245, 99386–99387, 99396–99397, 99401–99404 PLUS ICD-9-CM diagnosis codes: 733.00, 733.01, 733.02, 733.03, 733.09 CPT II codes: 4005F Allowed modifiers: 1P, 2P, 3P, 8P
#42 Osteoporosis: Counseling for vitamin D and calcium intake, and exercise	Documentation that the patient either is receiving both calcium and vitamin D or has been counseled for both calcium and vitamin D intake, and exercise at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99385–99387, 99395–99397, 99401–99404 PLUS ICD-9-CM diagnosis codes: 733.00, 733.01, 733.02, 733.03, 733.09 CPT II codes: 4019F Allowed modifiers: 1P and 8P
#48 Assessment of presence or absence of urinary incontinence in women aged 65 years and older	Documentation that patient was assessed for the presence or absence of urinary incontinence within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99387, 99397, 99401–99402 CPT II codes: 1090F Allowed modifiers: 1P and 8P
#49 Characterization of urinary incontinence in women aged 65 years and older	Documentation of frequency, volume, timing, type of symptoms, and how bothersome to the patient at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99387, 99397, 99401–99402 PLUS ICD-9-CM diagnosis codes: 307.6, 625.6, 788.30, 788.31, 788.32, 788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39 CPT II codes: 1091F Allowed modifiers: 8P
#50 Plan of care for urinary incontinence in women aged 65 years and older	Documentation that a plan of care for urinary incontinence was formulated at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99387, 99397, 99401–99402 PLUS ICD-9-CM diagnosis codes: 307.6, 625.6, 788.30, 788.31, 788.32, 788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39 CPT II codes: 0509F Allowed modifiers: 8P

The Centers for Medicare and Medicaid Services (CMS) launched its Physician Quality Reporting Initiative (PQRI) July 1. This program, voluntary in 2007, rewards physicians for reporting a designated set of quality measures. Physicians who successfully report these measures under established criteria earn a bonus payment, subject to a cap, of 1.5% of their total allowed charges for covered services paid under the Medicare physician fee schedule.

Quality measures are reported on the CMS claim form just as any other service would be, except that no charge is billed for the reported measure. The time frame established for the reporting of these measures is July 1 through December 31 of this year. Although there are plans to continue the program in 2008, it is unclear whether funds will be available for a bonus in 2009, and the measures for 2008 will be different from those used in 2007.

To calculate the potential bonus amount when at least 3 measures are successfully reported, use your total Medicare income for the past 6 months. If you received $60,000 for treating Medicare patients from January 1 through May 31, for example, and Medicare income has been steady, expect a lump sum bonus of $900 in mid-2008.

How do I report an intervention?

Good news: You do not have to register to participate in PQRI; you need only report the selected quality measures each time you submit a claim for the patient service to which the quality measure applies. Criteria for reporting (and then receiving the bonus in mid-2008) for these quality measures are as follows:

• Select the quality measures that apply most often to your practice (see the TABLE)
  
• Enter the PQRI codes on block 24D of the CMS 1500 claim form with a $0.00 dollar amount; if your system does not allow this amount to be entered, change it to $0.01
  
• There must be a match between the acceptable CPT or ICD-9 code reported for the overall service with a CPT Category II or HCPCS “G” code designated as the quality measure, as listed in the Medicare specifications file (www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage)
  
• Apply any applicable allowed modifier that explains why the quality measure was not assessed:
  

The measure specifications are organized to provide specific information:

• Measure title
  
• Description
  
• Instructions on reporting, including frequency, time frames, and applicability
  
• Numerator coding
  
• Definition of terms
  
• Coding instructions
  

For example: Measure 48 documents the percentage of female patients age 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months. The denominator for this measure is represented by the reported evaluation and management (E/M) service approved for this measure (ie, 99201–99205 [new patient E/M service], 99212–99215 [established patient E/M service], 99241– 99245 [outpatient consultation], 99387 [preventive new patient service], 99397 [preventive established patient service], 99401–99404 [preventive counseling visits]), along with the information on the claim that indicates the patient’s age and sex.

The numerator part of the measure is represented by a CPT Category II code with or without a modifier. CPT code 1090F (presence or absence of urinary stress incontinence assessed) would be reported if the presence or absence of urinary incontinence was assessed, but a modifier 1P is placed in box 24E of the claim form if you have documented a medical reason why this was not assessed, or modifier 8P if it was not assessed but the reason was not documented.

TABLE

The Physician Quality Reporting Initiative: 10 measures may apply to ObGyn practice in 2007

MEASURE	CONSTRAINTS AND COMMENTS
#20 Perioperative care: Timing of antibiotic prophylaxis—ordering physician	Documentation in medical record that drug was ordered or given 1–2 hours prior to surgery CPT codes applicable to gyn surgery: 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4047F or 4048F Allowed modifiers: 1P and 8P
#21 Perioperative care: Selection of prophylactic antibiotic—first- or second-generation cephalosporin	Documentation in medical record that cefazolin or cefuroxime was ordered or given CPT codes applicable to gyn surgery: 49000, 49002, 49010, 49180, 49200, 49201, 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4041F Allowed modifiers: 1P and 8P
#22 Perioperative care: Discontinuation of prophylactic antibiotic (non-cardiac procedures)	Documentation of an order for or evidence of discontinuation of prophylactic antibiotics within 24 hours of surgical end time, or specification of an antibiotic to be given in doses within that 24-hour period CPT codes applicable to gyn surgery: 58150, 58152, 58180, 58200, 58210, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294 CPT II codes: 4049F and 4946F Allowed modifiers: 1P and 8P
#23 Perioperative care: venous thromboembolism prophylaxis (when indicated in all patients)	Documentation in medical record of an order for low-molecular-weight heparin, low-dose unfractionated heparin, adjusted-dose warfarin, fondaparinux, or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time CPT codes applicable to gyn surgery: 49000, 49002, 49010, 49020, 49040, 49060, 49200, 49201, 56630, 56631, 56632, 56633, 56634, 56637, 56640, 58200, 58210, 58240, 58285, 58951, 58953, 58954, 58956 CPT II codes: 4044F Allowed modifiers: 1P and 8P
#39 Screening or therapy for osteoporosis for women 65 years and older	Documentation of an order for or performance of (with recorded results) a central dual-energy x-ray absorptiometry measurement performed at least once since age 60, or pharmacologic therapy prescribed within 12 months. Drugs include bisphosphonates, calcitonin, estrogens, parathyroid hormone, and selective estrogen receptor modulators Applicable E/M codes: 99201–99205, 99212–99215, 99387, 99397, 99401–99404 CPT II codes: 3096F, 3095F, or 4005F Allowed modifiers: 1P, 2P, 3P, 8P
#41 Osteoporosis: Pharmacotherapy	Documentation that the patient was prescribed pharmacologic therapy within 12 months. Applicable drugs are as listed in measure #39 above. Applicable E/M codes: 99201–99205, 99212–99215, 99241, 99242, 99243, 99244, 99245, 99386–99387, 99396–99397, 99401–99404 PLUS ICD-9-CM diagnosis codes: 733.00, 733.01, 733.02, 733.03, 733.09 CPT II codes: 4005F Allowed modifiers: 1P, 2P, 3P, 8P
#42 Osteoporosis: Counseling for vitamin D and calcium intake, and exercise	Documentation that the patient either is receiving both calcium and vitamin D or has been counseled for both calcium and vitamin D intake, and exercise at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99385–99387, 99395–99397, 99401–99404 PLUS ICD-9-CM diagnosis codes: 733.00, 733.01, 733.02, 733.03, 733.09 CPT II codes: 4019F Allowed modifiers: 1P and 8P
#48 Assessment of presence or absence of urinary incontinence in women aged 65 years and older	Documentation that patient was assessed for the presence or absence of urinary incontinence within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99387, 99397, 99401–99402 CPT II codes: 1090F Allowed modifiers: 1P and 8P
#49 Characterization of urinary incontinence in women aged 65 years and older	Documentation of frequency, volume, timing, type of symptoms, and how bothersome to the patient at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99387, 99397, 99401–99402 PLUS ICD-9-CM diagnosis codes: 307.6, 625.6, 788.30, 788.31, 788.32, 788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39 CPT II codes: 1091F Allowed modifiers: 8P
#50 Plan of care for urinary incontinence in women aged 65 years and older	Documentation that a plan of care for urinary incontinence was formulated at least once within 12 months Applicable E/M codes: 99201–99205, 99212–99215, 99241–99245, 99387, 99397, 99401–99402 PLUS ICD-9-CM diagnosis codes: 307.6, 625.6, 788.30, 788.31, 788.32, 788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39 CPT II codes: 0509F Allowed modifiers: 8P

Delayed delivery of twin #2 not a “multiple pregnancy”

Q. My patient delivered the first of her twins vaginally but is still carrying the second fetus. When we report our services, how should we code for both the first and (eventual) second delivery? I know that I will be billing 59409 (vaginal delivery only [with or without episiotomy and/or forceps]) for the first delivery and 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the second—assuming that a cesarean section is not required. But can I use the diagnosis code 761.5 (multiple pregnancy) with these codes, as well?

A. Here is one of those situations that ICD9 was not constructed to handle! You may not report 761.5 on the mother’s record because this is still one pregnancy for both events. Code 761.5 can only be reported on the baby’s record once he or she is receiving direct care. Therefore, report the twin diagnosis code 651.01 for both deliveries. However, consider waiting and billing the deliveries together, on the same claim, with the different delivery dates specified (as so: “4/21: 59409, 651.01”; then “5/xx: 59400, 651.01”), and include an explanation with the claim to ensure payment for both deliveries.

In-office lab test is not an occasion for a modifier

Q. We billed an office visit and a wet mount (87210 [smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)]). The lab service was determined to be global by the insurance company and was denied. What is the appropriate code for the wet mount?

A. The A modifier is usually unnecessary for a laboratory test with an office visit. The closest modifier that would apply is -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure).

I suspect that your problem may not be a global issue, but one of coverage for a lab test performed by your practice under CLIA (Clinical Laboratory Improvement Amendments). [Editor’s note: Details about coding for office lab tests (eg, wet mounts and KOH preps) in relation to CLIA certificate requirements were discussed in Reimbursement Adviser in the August 2006 issue of OBG Management. Read this installment at obgmanagement.com by linking to “Past Issues” on the top navigation bar of the home page.]

To sort out this situation, you first need to contact the payer to find out whether it considers a lab test global to an office visit, which should never be the case. Perhaps your billing staff misinterpreted the denial message. Or maybe this payer does, in fact, require a modifier for any service billed at the same time as an office visit.

On the other hand, it could also be that you do not have the required CLIA certificate to bill for the wet mount using code 87210.

Payer may balk at modified biophysical profile

Q. We are performing a limited ultrasonography to evaluate amniotic fluid volume and a fetal non-stress test at the same time on our pregnant patient. How can we best code this evaluation to ensure proper reimbursement?

A. No single code describes this modified (so to speak) biophysical profile. Instead, you have 2 coding options, either of which may cause a headache with the payer:

• Code for the complete biophysical profile (76818) but add a modifier -52 for a reduced service. The problem? Not all payers permit use of this modifier with an imaging code.
  
• Itemize your services by reporting 59025 for the fetal non-stress test and 76815 (limited pelvic ultrasound) for evaluation of amniotic fluid volume. The problem here? Code 59025 is bundled into code 76815; although you are allowed to use the modifier -59 (distinct procedural service) to bypass the edit, you can only do so if you can meet the criteria for doing so (eg, care involves a different incision or excision, a different patient encounter, or a different injury or site). Some payers may not accept that you’ve met those requirements, although I would disagree with that decision: Each test is performed independently and measures different things. So, to bill this combination of tests, add modifier -59 to the bundled code: 76815, 59025-59.
  

Hysteroscopy before but not during thermoablation

Q. Please clarify: How do we correctly report a thermoablation procedure when hysteroscopy is performed before the procedure but not for guidance during the procedure? Are 58353 (endometrial ablation, thermal, without hysteroscopic guidance) and 58555-51 (Hysteroscopy, diagnostic [separate procedure]; multiple procedure) appropriate codes?

 

A. The problem is that code 58555 is bundled into 58353 under National Correct Coding Initiative (NCCI) rules. Because of this, the modifier -51 (multiple procedures) cannot be used. Although this bundled code allows the use of a modifier -59 (distinct procedure), meeting the criteria for using it is almost impossible.

Modifier -59 is defined as follows in CPT: “…used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.”

In the situation that you describe, the hysteroscope was inserted in the same area as the ablation, not at a different site; no separate excision or incision was made when inserting the hysteroscope; this was not a different surgical session; and, last, although hysteroscopy might, technically, be a distinct procedure from the ablation, it was directly related to the performance of the ablation in that it represented initial “exploration.”

I believe, therefore, that correct coding in this case is to report the all-inclusive 58563 (Hysteroscopy, surgical; with endometrial ablation [eg, endometrial resection, electrosurgical ablation, thermoablation]). Support for this opinion is found in ACOG’s Ob/GYN Coding Manual: Components of Correct Procedural Coding 2007. A comment included with code 58353 states: “If hysteroscopy is also performed, report code 58563 instead.”

Delayed delivery of twin #2 not a “multiple pregnancy”

Q. My patient delivered the first of her twins vaginally but is still carrying the second fetus. When we report our services, how should we code for both the first and (eventual) second delivery? I know that I will be billing 59409 (vaginal delivery only [with or without episiotomy and/or forceps]) for the first delivery and 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the second—assuming that a cesarean section is not required. But can I use the diagnosis code 761.5 (multiple pregnancy) with these codes, as well?

A. Here is one of those situations that ICD9 was not constructed to handle! You may not report 761.5 on the mother’s record because this is still one pregnancy for both events. Code 761.5 can only be reported on the baby’s record once he or she is receiving direct care. Therefore, report the twin diagnosis code 651.01 for both deliveries. However, consider waiting and billing the deliveries together, on the same claim, with the different delivery dates specified (as so: “4/21: 59409, 651.01”; then “5/xx: 59400, 651.01”), and include an explanation with the claim to ensure payment for both deliveries.

In-office lab test is not an occasion for a modifier

Q. We billed an office visit and a wet mount (87210 [smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)]). The lab service was determined to be global by the insurance company and was denied. What is the appropriate code for the wet mount?

A. The A modifier is usually unnecessary for a laboratory test with an office visit. The closest modifier that would apply is -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure).

I suspect that your problem may not be a global issue, but one of coverage for a lab test performed by your practice under CLIA (Clinical Laboratory Improvement Amendments). [Editor’s note: Details about coding for office lab tests (eg, wet mounts and KOH preps) in relation to CLIA certificate requirements were discussed in Reimbursement Adviser in the August 2006 issue of OBG Management. Read this installment at obgmanagement.com by linking to “Past Issues” on the top navigation bar of the home page.]

To sort out this situation, you first need to contact the payer to find out whether it considers a lab test global to an office visit, which should never be the case. Perhaps your billing staff misinterpreted the denial message. Or maybe this payer does, in fact, require a modifier for any service billed at the same time as an office visit.

On the other hand, it could also be that you do not have the required CLIA certificate to bill for the wet mount using code 87210.

Payer may balk at modified biophysical profile

Q. We are performing a limited ultrasonography to evaluate amniotic fluid volume and a fetal non-stress test at the same time on our pregnant patient. How can we best code this evaluation to ensure proper reimbursement?

A. No single code describes this modified (so to speak) biophysical profile. Instead, you have 2 coding options, either of which may cause a headache with the payer:

• Code for the complete biophysical profile (76818) but add a modifier -52 for a reduced service. The problem? Not all payers permit use of this modifier with an imaging code.
  
• Itemize your services by reporting 59025 for the fetal non-stress test and 76815 (limited pelvic ultrasound) for evaluation of amniotic fluid volume. The problem here? Code 59025 is bundled into code 76815; although you are allowed to use the modifier -59 (distinct procedural service) to bypass the edit, you can only do so if you can meet the criteria for doing so (eg, care involves a different incision or excision, a different patient encounter, or a different injury or site). Some payers may not accept that you’ve met those requirements, although I would disagree with that decision: Each test is performed independently and measures different things. So, to bill this combination of tests, add modifier -59 to the bundled code: 76815, 59025-59.
  

Hysteroscopy before but not during thermoablation

Q. Please clarify: How do we correctly report a thermoablation procedure when hysteroscopy is performed before the procedure but not for guidance during the procedure? Are 58353 (endometrial ablation, thermal, without hysteroscopic guidance) and 58555-51 (Hysteroscopy, diagnostic [separate procedure]; multiple procedure) appropriate codes?

 

A. The problem is that code 58555 is bundled into 58353 under National Correct Coding Initiative (NCCI) rules. Because of this, the modifier -51 (multiple procedures) cannot be used. Although this bundled code allows the use of a modifier -59 (distinct procedure), meeting the criteria for using it is almost impossible.

Modifier -59 is defined as follows in CPT: “…used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.”

In the situation that you describe, the hysteroscope was inserted in the same area as the ablation, not at a different site; no separate excision or incision was made when inserting the hysteroscope; this was not a different surgical session; and, last, although hysteroscopy might, technically, be a distinct procedure from the ablation, it was directly related to the performance of the ablation in that it represented initial “exploration.”

I believe, therefore, that correct coding in this case is to report the all-inclusive 58563 (Hysteroscopy, surgical; with endometrial ablation [eg, endometrial resection, electrosurgical ablation, thermoablation]). Support for this opinion is found in ACOG’s Ob/GYN Coding Manual: Components of Correct Procedural Coding 2007. A comment included with code 58353 states: “If hysteroscopy is also performed, report code 58563 instead.”

Delayed delivery of twin #2 not a “multiple pregnancy”

Q. My patient delivered the first of her twins vaginally but is still carrying the second fetus. When we report our services, how should we code for both the first and (eventual) second delivery? I know that I will be billing 59409 (vaginal delivery only [with or without episiotomy and/or forceps]) for the first delivery and 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the second—assuming that a cesarean section is not required. But can I use the diagnosis code 761.5 (multiple pregnancy) with these codes, as well?

A. Here is one of those situations that ICD9 was not constructed to handle! You may not report 761.5 on the mother’s record because this is still one pregnancy for both events. Code 761.5 can only be reported on the baby’s record once he or she is receiving direct care. Therefore, report the twin diagnosis code 651.01 for both deliveries. However, consider waiting and billing the deliveries together, on the same claim, with the different delivery dates specified (as so: “4/21: 59409, 651.01”; then “5/xx: 59400, 651.01”), and include an explanation with the claim to ensure payment for both deliveries.

In-office lab test is not an occasion for a modifier

Q. We billed an office visit and a wet mount (87210 [smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)]). The lab service was determined to be global by the insurance company and was denied. What is the appropriate code for the wet mount?

A. The A modifier is usually unnecessary for a laboratory test with an office visit. The closest modifier that would apply is -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure).

I suspect that your problem may not be a global issue, but one of coverage for a lab test performed by your practice under CLIA (Clinical Laboratory Improvement Amendments). [Editor’s note: Details about coding for office lab tests (eg, wet mounts and KOH preps) in relation to CLIA certificate requirements were discussed in Reimbursement Adviser in the August 2006 issue of OBG Management. Read this installment at obgmanagement.com by linking to “Past Issues” on the top navigation bar of the home page.]

To sort out this situation, you first need to contact the payer to find out whether it considers a lab test global to an office visit, which should never be the case. Perhaps your billing staff misinterpreted the denial message. Or maybe this payer does, in fact, require a modifier for any service billed at the same time as an office visit.

On the other hand, it could also be that you do not have the required CLIA certificate to bill for the wet mount using code 87210.

Payer may balk at modified biophysical profile

Q. We are performing a limited ultrasonography to evaluate amniotic fluid volume and a fetal non-stress test at the same time on our pregnant patient. How can we best code this evaluation to ensure proper reimbursement?

A. No single code describes this modified (so to speak) biophysical profile. Instead, you have 2 coding options, either of which may cause a headache with the payer:

• Code for the complete biophysical profile (76818) but add a modifier -52 for a reduced service. The problem? Not all payers permit use of this modifier with an imaging code.
  
• Itemize your services by reporting 59025 for the fetal non-stress test and 76815 (limited pelvic ultrasound) for evaluation of amniotic fluid volume. The problem here? Code 59025 is bundled into code 76815; although you are allowed to use the modifier -59 (distinct procedural service) to bypass the edit, you can only do so if you can meet the criteria for doing so (eg, care involves a different incision or excision, a different patient encounter, or a different injury or site). Some payers may not accept that you’ve met those requirements, although I would disagree with that decision: Each test is performed independently and measures different things. So, to bill this combination of tests, add modifier -59 to the bundled code: 76815, 59025-59.
  

Hysteroscopy before but not during thermoablation

Q. Please clarify: How do we correctly report a thermoablation procedure when hysteroscopy is performed before the procedure but not for guidance during the procedure? Are 58353 (endometrial ablation, thermal, without hysteroscopic guidance) and 58555-51 (Hysteroscopy, diagnostic [separate procedure]; multiple procedure) appropriate codes?

 

A. The problem is that code 58555 is bundled into 58353 under National Correct Coding Initiative (NCCI) rules. Because of this, the modifier -51 (multiple procedures) cannot be used. Although this bundled code allows the use of a modifier -59 (distinct procedure), meeting the criteria for using it is almost impossible.

Modifier -59 is defined as follows in CPT: “…used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.”

In the situation that you describe, the hysteroscope was inserted in the same area as the ablation, not at a different site; no separate excision or incision was made when inserting the hysteroscope; this was not a different surgical session; and, last, although hysteroscopy might, technically, be a distinct procedure from the ablation, it was directly related to the performance of the ablation in that it represented initial “exploration.”

I believe, therefore, that correct coding in this case is to report the all-inclusive 58563 (Hysteroscopy, surgical; with endometrial ablation [eg, endometrial resection, electrosurgical ablation, thermoablation]). Support for this opinion is found in ACOG’s Ob/GYN Coding Manual: Components of Correct Procedural Coding 2007. A comment included with code 58353 states: “If hysteroscopy is also performed, report code 58563 instead.”

Be consistent with the fifth digit across delivery codes!

Q. Recently, we were denied a claim for hospital care related to a patient’s premature labor. She was admitted to stop labor at 30 weeks but delivered 5 days after admission. The reason for denial? “Invalid ICD9 code.” But the code we used, 644.03 (threatened premature labor), appears to be correct. We also reported 644.21 (early onset of delivery) with the delivery code. Should we appeal, given that care prior to delivery is well documented?

A. I believe that your denial is based on incorrect use of the fifth digit on the reported diagnosis codes, not on refusal to reimburse separately for additional care before delivery. ICD9 guidelines related to fifth-digit coding for obstetric cases state:

“The fifth-digits, which are appropriate for each code number, are listed in brackets under each code. The fifth digits on each code should all be consistent with each other. That is, should a delivery occur all of the fifth digits should indicate the delivery.”

In this case, although the patient was still in the antepartum period during initial care, she did deliver during that hospitalization. That means a fifth digit of “3” (antepartum condition or complication) is incompatible with a fifth digit of “1” (delivered, with or without mention of antepartum condition), which is probably what generated the denial message. You have 2 choices:

• Resubmit a corrected claim, indicating a fifth digit of “1” for both diagnostic codes
  
• Appeal the denial, indicating the diagnostic correction and supplying information regarding the additional care for this patient.
  

I recommend the second option if you have reason to believe that the payer might also deny the additional care without this information.

Bundle codes for repair of a pelvic floor defect?

Q. To treat a patient who has a pelvic floor defect, we performed an anterior repair, a posterior repair, and an enterocele repair, using mesh—plus cystoscopy. Does one code capture all these procedures?

A. I assume that you used mesh to augment the anterior and posterior repairs. A single CPT code, 57265 (combined anteroposterior colporrhaphy; with enterocele repair) captures the first 3 procedures, and CPT allows the addon mesh code 57267 (insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach) to be reported with 57265.

Based on the definition of the addon mesh code, it is appropriate for you to bill for a quantity of 2: 1 for the anterior compartment repair and 1 for the posterior compartment repair, which includes the rectocele and enterocele.

As for reporting the cystoscopy (with 52000 [cystourethroscopy (separate procedure)]), the reason that you provide for the procedure will determine whether you are reimbursed. There must be a medical indication for cystoscopy beyond your simply checking your work, which is considered a standard of surgical care by most payers.

Be consistent with the fifth digit across delivery codes!

Q. Recently, we were denied a claim for hospital care related to a patient’s premature labor. She was admitted to stop labor at 30 weeks but delivered 5 days after admission. The reason for denial? “Invalid ICD9 code.” But the code we used, 644.03 (threatened premature labor), appears to be correct. We also reported 644.21 (early onset of delivery) with the delivery code. Should we appeal, given that care prior to delivery is well documented?

A. I believe that your denial is based on incorrect use of the fifth digit on the reported diagnosis codes, not on refusal to reimburse separately for additional care before delivery. ICD9 guidelines related to fifth-digit coding for obstetric cases state:

“The fifth-digits, which are appropriate for each code number, are listed in brackets under each code. The fifth digits on each code should all be consistent with each other. That is, should a delivery occur all of the fifth digits should indicate the delivery.”

In this case, although the patient was still in the antepartum period during initial care, she did deliver during that hospitalization. That means a fifth digit of “3” (antepartum condition or complication) is incompatible with a fifth digit of “1” (delivered, with or without mention of antepartum condition), which is probably what generated the denial message. You have 2 choices:

• Resubmit a corrected claim, indicating a fifth digit of “1” for both diagnostic codes
  
• Appeal the denial, indicating the diagnostic correction and supplying information regarding the additional care for this patient.
  

I recommend the second option if you have reason to believe that the payer might also deny the additional care without this information.

Bundle codes for repair of a pelvic floor defect?

Q. To treat a patient who has a pelvic floor defect, we performed an anterior repair, a posterior repair, and an enterocele repair, using mesh—plus cystoscopy. Does one code capture all these procedures?

A. I assume that you used mesh to augment the anterior and posterior repairs. A single CPT code, 57265 (combined anteroposterior colporrhaphy; with enterocele repair) captures the first 3 procedures, and CPT allows the addon mesh code 57267 (insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach) to be reported with 57265.

Based on the definition of the addon mesh code, it is appropriate for you to bill for a quantity of 2: 1 for the anterior compartment repair and 1 for the posterior compartment repair, which includes the rectocele and enterocele.

As for reporting the cystoscopy (with 52000 [cystourethroscopy (separate procedure)]), the reason that you provide for the procedure will determine whether you are reimbursed. There must be a medical indication for cystoscopy beyond your simply checking your work, which is considered a standard of surgical care by most payers.

Be consistent with the fifth digit across delivery codes!

Q. Recently, we were denied a claim for hospital care related to a patient’s premature labor. She was admitted to stop labor at 30 weeks but delivered 5 days after admission. The reason for denial? “Invalid ICD9 code.” But the code we used, 644.03 (threatened premature labor), appears to be correct. We also reported 644.21 (early onset of delivery) with the delivery code. Should we appeal, given that care prior to delivery is well documented?

A. I believe that your denial is based on incorrect use of the fifth digit on the reported diagnosis codes, not on refusal to reimburse separately for additional care before delivery. ICD9 guidelines related to fifth-digit coding for obstetric cases state:

“The fifth-digits, which are appropriate for each code number, are listed in brackets under each code. The fifth digits on each code should all be consistent with each other. That is, should a delivery occur all of the fifth digits should indicate the delivery.”

In this case, although the patient was still in the antepartum period during initial care, she did deliver during that hospitalization. That means a fifth digit of “3” (antepartum condition or complication) is incompatible with a fifth digit of “1” (delivered, with or without mention of antepartum condition), which is probably what generated the denial message. You have 2 choices:

• Resubmit a corrected claim, indicating a fifth digit of “1” for both diagnostic codes
  
• Appeal the denial, indicating the diagnostic correction and supplying information regarding the additional care for this patient.
  

I recommend the second option if you have reason to believe that the payer might also deny the additional care without this information.

Bundle codes for repair of a pelvic floor defect?

Q. To treat a patient who has a pelvic floor defect, we performed an anterior repair, a posterior repair, and an enterocele repair, using mesh—plus cystoscopy. Does one code capture all these procedures?

A. I assume that you used mesh to augment the anterior and posterior repairs. A single CPT code, 57265 (combined anteroposterior colporrhaphy; with enterocele repair) captures the first 3 procedures, and CPT allows the addon mesh code 57267 (insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach) to be reported with 57265.

Based on the definition of the addon mesh code, it is appropriate for you to bill for a quantity of 2: 1 for the anterior compartment repair and 1 for the posterior compartment repair, which includes the rectocele and enterocele.

As for reporting the cystoscopy (with 52000 [cystourethroscopy (separate procedure)]), the reason that you provide for the procedure will determine whether you are reimbursed. There must be a medical indication for cystoscopy beyond your simply checking your work, which is considered a standard of surgical care by most payers.

Does breast exam only qualify as screening visit?

Q. I recently saw a 62-year-old Medicare patient for a breast examination only. Here is my documentation of the visit:

• Patient is a virgin, takes no hormones, and refuses a pelvic exam and Pap smear. Blood pressure is in the normal range. Body mass index is 21. She reports no problems and has no questions.
  
• Examination of breasts reveals normal skin and nipples, no masses or tenderness, and no lymph-node swelling.
  
• Patient is given a slip for a routine mammogram and instructions on performing breast self-exam, and is instructed to return in 1 year, barring problems or concerns.
  

My question is: Does this visit qualify for billing Medicare with code G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) or should it be billed a low-level problem E/M service instead? We would use the diagnosis code V76.19 (other screening breast examination).

A. You face an interesting situation. This is a preventive service, but a diagnosis of V76.19, although accurate here, will cause code G0101, which requires that a pelvic exam have been performed, to be denied.

If you report this visit as a problem E/M service using only this diagnosis, on the other hand, you are more than likely to be denied by Medicare.

For Medicare to consider this a covered service billed as a problem E/M service, you would also have to list diagnostic codes that indicate a complaint, a history of a breast condition, or a strong family history of breast cancer. Medicare will pay for the screening mammogram, but the screening breast exam by itself may not be considered a covered service.

You have a few options:

• Contact the Medicare carrier and explain the situation. See if they propose a coding solution that they will accept. Get their answer in writing!
  
• Bill Medicare using a low-level E/M code (eg, 99212, problem focused exam with straightforward medical decision making) linked to the diagnosis code V76.19. If you choose this option, have the patient sign a waiver that she is responsible for payment should Medicare deny the service. Add the modifier –GA (waiver of liability statement on file) to the problem E/M code. This will allow you to collect payment from the patient.
  
• Submit the unlisted code or preventive services 99429 because you performed an exam—although not one that meets the criteria of age-specific preventive codes. This code is never reimbursed by Medicare, but once you get a denial, you either can collect from the patient or are able to submit the charge to any secondary insurance she might have. A modifier –GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) would also need to be added to the preventive medicine code.
  

Fern testing: CLIA-waived but payer might not cover

Q. What is the correct code for fern testing? The codes recommended to us are 89060 or 87210, not Q0114, which isn’t recognized by some of our payers. Can you give us advice?

A. The fern test should never be coded 87210 because that code does not represent how the test is performed. (Fern testing is simply applying vaginal fluid to a slide, which is left to dry, and observing whether a ferning develops when the residue is viewed under a microscope.) The test is performed by the provider, not the laboratory; as such, Q0114 is the correct code.

Code 87210, in addition to requiring addition of saline or potassium chloride, is not a CLIA-waived test. You would not be able to bill for it unless you have an advanced lab certificate.

Code 89060 is assigned when looking for crystals in synovial fluid. It is also not a CLIA-waived or physician-performed microscopy test, so billing using this code would require an advanced lab certificate as well.

The advent of the national code set has meant that your payers are required to recognize all codes, although they can determine whether to cover a service or not. It may be that this test isn’t covered by your payer, rather than the code not being recognized as correct.

Two voiding studies: Bill together but specify parts

Q. Can both the 51795 voiding pressure study and 51797 intra-abdominal voiding pressure study be billed together? When I checked the bundling software, it lists these codes as mutually exclusive, with 51795 having an indicator of “1” and 51797 a “9.” If the codes can be billed together, should I use a modifier -59 (distinct service)?

 

A. Voiding pressure studies (51795) measure urinary flow rate and pressure during bladder emptying; intra-abdominal voiding pressure studies (51797) measure how the patient must strain to void. These codes can be billed together because they measure different events. More important, they are not bundled.

The “9” indicator used by Medicare for bundled codes means that the edit was deleted. In this case, it was deleted on the same date it was added. For some reason, Medicare elects not to remove deleted code pairs from the master database. Although you will get paid for both of these codes, the code order is different depending on whether you are using your own equipment (because of differences in relative value units).

If you bill each test with a modifier -26 (professional component only), you do not own the equipment and the place of service is a facility. In that case, list 51797-26 first and 51795-26-51 second. The modifier -51 is used on the second code because this is a multiple procedure. If you are billing both professional and technical components (ie, you are using your equipment, in the office), billing order is reversed: List 51797 first and 51795-51 second. Do not use a modifier -59 with this code combination.

Fetal genetic abnormality inferred from US; code for further study

Q. What diagnosis code should we use for a bilateral choroid plexus cyst found on ultrasonography?

A. Choroid plexus cysts (CPCs) are considered a “soft marker” for a gene abnormality called Edward’s syndrome. Although these markers, taken alone, do the baby no harm, they may be associated with an increased risk of another abnormality, including cardiac defects. The presence of a soft marker is not diagnostic of this other abnormality; it is just a noted association.

At the time of the sonogram, therefore, you can only suspect a problem with the fetal genes; further testing is required. In that case, report 655.13 (known or suspected chromosomal abnormality of the fetus affecting management of mother; antepartum condition or complication) with a secondary diagnosis of 793.99 (other nonspecific abnormal findings on radiological and other examinations of body structure).

Positive ANA—don’t leap to “autoimmune disorder”

Q. One of our obstetric patients had a positive antinuclear antibody (ANA) test. We‘ll follow her with biophysical profiles and non-stress testing, and track amniotic fluid volume. Because we have not yet diagnosed systemic lupus erythematosus (SLE) or other specific condition, is it appropriate to use a diagnosis of unspecified autoimmune disorder (279.4) in addition to a pregnancy complication code?

A. Many illnesses and conditions are associated with a positive ANA, including rheumatoid arthritis, Sjögren syndrome, scleroderma, and SLE; infectious diseases such as mononucleosis; and autoimmune thyroid and liver disease. Some medications can cause a positive ANA, and many healthy people have a positive ANA.

Because you have not eliminated the other possibilities for the positive ANA, it is premature to assign the code for an autoimmune condition. Instead, report 648.93 as your primary code (Other current conditions in the mother classifiable elsewhere, complicating pregnancy, childbirth, or the puerperium; antepartum condition or complication), with the secondary diagnosis code 795.79 (Other and unspecified nonspecific immunological findings).

Coding Zoladex depends on the patient’s condition

Q. We have begun using Zoladex for our patients. How do we best code for administering this agent? We have been told to use chemotherapy codes, but this is not a chemotherapeutic agent.

A. Zoladex (goserelin acetate) is classified as a hormonal antineoplastic. It is used to treat endometriosis before surgery because it thins the lining of the uterus, and to treat breast cancer by inhibiting production of estrogen.

The drug is supplied as tiny pellets, which are injected under the skin of the abdomen using a small, “trocar-like” needle and syringe. The procedure constitutes an injection. If you are treating breast cancer with this drug, the correct code would be 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic). The code for the pellets is J9202 (Goserelin acetate implant, per 3.6 mg). If you administer more than 3.6 mg at a time, remember to adjust the quantity you bill for. If you are using this drug to treat endometriosis or fibroids, CPT directs you to report 90772 for the injection because it is then considered a nonantineoplastic hormone injection.

Call a contraceptive a contraceptive when coding

Q. How should we code for Implanon insertions?

A. Code this S0180 (Etonogestrel [contraceptive] implant system, including implants and supplies). For the procedure, I recommend code 11975 (insertion, implantable contraceptive capsules).

Implanon’s manufacturer thinks the correct code is 11981 (Insertion, nonbiodegradable drug delivery implant), but I disagree: This is a contraceptive that is implanted under the skin and, under CPT rules, you must use the code that most closely describes the procedure.

 

Note also that, although Implanon involves insertion of one rod (other systems require insertion of several), the code 11981 has greater relative value units than 11975. This payment difference will not be lost on most payers because the diagnostic link for the procedure, whichever code is reported, is V25.5 (insertion of implantable subdermal contraceptive).

Does breast exam only qualify as screening visit?

Q. I recently saw a 62-year-old Medicare patient for a breast examination only. Here is my documentation of the visit:

• Patient is a virgin, takes no hormones, and refuses a pelvic exam and Pap smear. Blood pressure is in the normal range. Body mass index is 21. She reports no problems and has no questions.
  
• Examination of breasts reveals normal skin and nipples, no masses or tenderness, and no lymph-node swelling.
  
• Patient is given a slip for a routine mammogram and instructions on performing breast self-exam, and is instructed to return in 1 year, barring problems or concerns.
  

My question is: Does this visit qualify for billing Medicare with code G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) or should it be billed a low-level problem E/M service instead? We would use the diagnosis code V76.19 (other screening breast examination).

A. You face an interesting situation. This is a preventive service, but a diagnosis of V76.19, although accurate here, will cause code G0101, which requires that a pelvic exam have been performed, to be denied.

If you report this visit as a problem E/M service using only this diagnosis, on the other hand, you are more than likely to be denied by Medicare.

For Medicare to consider this a covered service billed as a problem E/M service, you would also have to list diagnostic codes that indicate a complaint, a history of a breast condition, or a strong family history of breast cancer. Medicare will pay for the screening mammogram, but the screening breast exam by itself may not be considered a covered service.

You have a few options:

• Contact the Medicare carrier and explain the situation. See if they propose a coding solution that they will accept. Get their answer in writing!
  
• Bill Medicare using a low-level E/M code (eg, 99212, problem focused exam with straightforward medical decision making) linked to the diagnosis code V76.19. If you choose this option, have the patient sign a waiver that she is responsible for payment should Medicare deny the service. Add the modifier –GA (waiver of liability statement on file) to the problem E/M code. This will allow you to collect payment from the patient.
  
• Submit the unlisted code or preventive services 99429 because you performed an exam—although not one that meets the criteria of age-specific preventive codes. This code is never reimbursed by Medicare, but once you get a denial, you either can collect from the patient or are able to submit the charge to any secondary insurance she might have. A modifier –GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) would also need to be added to the preventive medicine code.
  

Fern testing: CLIA-waived but payer might not cover

Q. What is the correct code for fern testing? The codes recommended to us are 89060 or 87210, not Q0114, which isn’t recognized by some of our payers. Can you give us advice?

A. The fern test should never be coded 87210 because that code does not represent how the test is performed. (Fern testing is simply applying vaginal fluid to a slide, which is left to dry, and observing whether a ferning develops when the residue is viewed under a microscope.) The test is performed by the provider, not the laboratory; as such, Q0114 is the correct code.

Code 87210, in addition to requiring addition of saline or potassium chloride, is not a CLIA-waived test. You would not be able to bill for it unless you have an advanced lab certificate.

Code 89060 is assigned when looking for crystals in synovial fluid. It is also not a CLIA-waived or physician-performed microscopy test, so billing using this code would require an advanced lab certificate as well.

The advent of the national code set has meant that your payers are required to recognize all codes, although they can determine whether to cover a service or not. It may be that this test isn’t covered by your payer, rather than the code not being recognized as correct.

Two voiding studies: Bill together but specify parts

Q. Can both the 51795 voiding pressure study and 51797 intra-abdominal voiding pressure study be billed together? When I checked the bundling software, it lists these codes as mutually exclusive, with 51795 having an indicator of “1” and 51797 a “9.” If the codes can be billed together, should I use a modifier -59 (distinct service)?

 

A. Voiding pressure studies (51795) measure urinary flow rate and pressure during bladder emptying; intra-abdominal voiding pressure studies (51797) measure how the patient must strain to void. These codes can be billed together because they measure different events. More important, they are not bundled.

The “9” indicator used by Medicare for bundled codes means that the edit was deleted. In this case, it was deleted on the same date it was added. For some reason, Medicare elects not to remove deleted code pairs from the master database. Although you will get paid for both of these codes, the code order is different depending on whether you are using your own equipment (because of differences in relative value units).

If you bill each test with a modifier -26 (professional component only), you do not own the equipment and the place of service is a facility. In that case, list 51797-26 first and 51795-26-51 second. The modifier -51 is used on the second code because this is a multiple procedure. If you are billing both professional and technical components (ie, you are using your equipment, in the office), billing order is reversed: List 51797 first and 51795-51 second. Do not use a modifier -59 with this code combination.

Fetal genetic abnormality inferred from US; code for further study

Q. What diagnosis code should we use for a bilateral choroid plexus cyst found on ultrasonography?

A. Choroid plexus cysts (CPCs) are considered a “soft marker” for a gene abnormality called Edward’s syndrome. Although these markers, taken alone, do the baby no harm, they may be associated with an increased risk of another abnormality, including cardiac defects. The presence of a soft marker is not diagnostic of this other abnormality; it is just a noted association.

At the time of the sonogram, therefore, you can only suspect a problem with the fetal genes; further testing is required. In that case, report 655.13 (known or suspected chromosomal abnormality of the fetus affecting management of mother; antepartum condition or complication) with a secondary diagnosis of 793.99 (other nonspecific abnormal findings on radiological and other examinations of body structure).

Positive ANA—don’t leap to “autoimmune disorder”

Q. One of our obstetric patients had a positive antinuclear antibody (ANA) test. We‘ll follow her with biophysical profiles and non-stress testing, and track amniotic fluid volume. Because we have not yet diagnosed systemic lupus erythematosus (SLE) or other specific condition, is it appropriate to use a diagnosis of unspecified autoimmune disorder (279.4) in addition to a pregnancy complication code?

A. Many illnesses and conditions are associated with a positive ANA, including rheumatoid arthritis, Sjögren syndrome, scleroderma, and SLE; infectious diseases such as mononucleosis; and autoimmune thyroid and liver disease. Some medications can cause a positive ANA, and many healthy people have a positive ANA.

Because you have not eliminated the other possibilities for the positive ANA, it is premature to assign the code for an autoimmune condition. Instead, report 648.93 as your primary code (Other current conditions in the mother classifiable elsewhere, complicating pregnancy, childbirth, or the puerperium; antepartum condition or complication), with the secondary diagnosis code 795.79 (Other and unspecified nonspecific immunological findings).

Coding Zoladex depends on the patient’s condition

Q. We have begun using Zoladex for our patients. How do we best code for administering this agent? We have been told to use chemotherapy codes, but this is not a chemotherapeutic agent.

A. Zoladex (goserelin acetate) is classified as a hormonal antineoplastic. It is used to treat endometriosis before surgery because it thins the lining of the uterus, and to treat breast cancer by inhibiting production of estrogen.

The drug is supplied as tiny pellets, which are injected under the skin of the abdomen using a small, “trocar-like” needle and syringe. The procedure constitutes an injection. If you are treating breast cancer with this drug, the correct code would be 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic). The code for the pellets is J9202 (Goserelin acetate implant, per 3.6 mg). If you administer more than 3.6 mg at a time, remember to adjust the quantity you bill for. If you are using this drug to treat endometriosis or fibroids, CPT directs you to report 90772 for the injection because it is then considered a nonantineoplastic hormone injection.

Call a contraceptive a contraceptive when coding

Q. How should we code for Implanon insertions?

A. Code this S0180 (Etonogestrel [contraceptive] implant system, including implants and supplies). For the procedure, I recommend code 11975 (insertion, implantable contraceptive capsules).

Implanon’s manufacturer thinks the correct code is 11981 (Insertion, nonbiodegradable drug delivery implant), but I disagree: This is a contraceptive that is implanted under the skin and, under CPT rules, you must use the code that most closely describes the procedure.

 

Note also that, although Implanon involves insertion of one rod (other systems require insertion of several), the code 11981 has greater relative value units than 11975. This payment difference will not be lost on most payers because the diagnostic link for the procedure, whichever code is reported, is V25.5 (insertion of implantable subdermal contraceptive).

Does breast exam only qualify as screening visit?

Q. I recently saw a 62-year-old Medicare patient for a breast examination only. Here is my documentation of the visit:

• Patient is a virgin, takes no hormones, and refuses a pelvic exam and Pap smear. Blood pressure is in the normal range. Body mass index is 21. She reports no problems and has no questions.
  
• Examination of breasts reveals normal skin and nipples, no masses or tenderness, and no lymph-node swelling.
  
• Patient is given a slip for a routine mammogram and instructions on performing breast self-exam, and is instructed to return in 1 year, barring problems or concerns.
  

My question is: Does this visit qualify for billing Medicare with code G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) or should it be billed a low-level problem E/M service instead? We would use the diagnosis code V76.19 (other screening breast examination).

A. You face an interesting situation. This is a preventive service, but a diagnosis of V76.19, although accurate here, will cause code G0101, which requires that a pelvic exam have been performed, to be denied.

If you report this visit as a problem E/M service using only this diagnosis, on the other hand, you are more than likely to be denied by Medicare.

For Medicare to consider this a covered service billed as a problem E/M service, you would also have to list diagnostic codes that indicate a complaint, a history of a breast condition, or a strong family history of breast cancer. Medicare will pay for the screening mammogram, but the screening breast exam by itself may not be considered a covered service.

You have a few options:

• Contact the Medicare carrier and explain the situation. See if they propose a coding solution that they will accept. Get their answer in writing!
  
• Bill Medicare using a low-level E/M code (eg, 99212, problem focused exam with straightforward medical decision making) linked to the diagnosis code V76.19. If you choose this option, have the patient sign a waiver that she is responsible for payment should Medicare deny the service. Add the modifier –GA (waiver of liability statement on file) to the problem E/M code. This will allow you to collect payment from the patient.
  
• Submit the unlisted code or preventive services 99429 because you performed an exam—although not one that meets the criteria of age-specific preventive codes. This code is never reimbursed by Medicare, but once you get a denial, you either can collect from the patient or are able to submit the charge to any secondary insurance she might have. A modifier –GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) would also need to be added to the preventive medicine code.
  

Fern testing: CLIA-waived but payer might not cover

Q. What is the correct code for fern testing? The codes recommended to us are 89060 or 87210, not Q0114, which isn’t recognized by some of our payers. Can you give us advice?

A. The fern test should never be coded 87210 because that code does not represent how the test is performed. (Fern testing is simply applying vaginal fluid to a slide, which is left to dry, and observing whether a ferning develops when the residue is viewed under a microscope.) The test is performed by the provider, not the laboratory; as such, Q0114 is the correct code.

Code 87210, in addition to requiring addition of saline or potassium chloride, is not a CLIA-waived test. You would not be able to bill for it unless you have an advanced lab certificate.

Code 89060 is assigned when looking for crystals in synovial fluid. It is also not a CLIA-waived or physician-performed microscopy test, so billing using this code would require an advanced lab certificate as well.

The advent of the national code set has meant that your payers are required to recognize all codes, although they can determine whether to cover a service or not. It may be that this test isn’t covered by your payer, rather than the code not being recognized as correct.

Two voiding studies: Bill together but specify parts

Q. Can both the 51795 voiding pressure study and 51797 intra-abdominal voiding pressure study be billed together? When I checked the bundling software, it lists these codes as mutually exclusive, with 51795 having an indicator of “1” and 51797 a “9.” If the codes can be billed together, should I use a modifier -59 (distinct service)?

 

A. Voiding pressure studies (51795) measure urinary flow rate and pressure during bladder emptying; intra-abdominal voiding pressure studies (51797) measure how the patient must strain to void. These codes can be billed together because they measure different events. More important, they are not bundled.

The “9” indicator used by Medicare for bundled codes means that the edit was deleted. In this case, it was deleted on the same date it was added. For some reason, Medicare elects not to remove deleted code pairs from the master database. Although you will get paid for both of these codes, the code order is different depending on whether you are using your own equipment (because of differences in relative value units).

If you bill each test with a modifier -26 (professional component only), you do not own the equipment and the place of service is a facility. In that case, list 51797-26 first and 51795-26-51 second. The modifier -51 is used on the second code because this is a multiple procedure. If you are billing both professional and technical components (ie, you are using your equipment, in the office), billing order is reversed: List 51797 first and 51795-51 second. Do not use a modifier -59 with this code combination.

Fetal genetic abnormality inferred from US; code for further study

Q. What diagnosis code should we use for a bilateral choroid plexus cyst found on ultrasonography?

A. Choroid plexus cysts (CPCs) are considered a “soft marker” for a gene abnormality called Edward’s syndrome. Although these markers, taken alone, do the baby no harm, they may be associated with an increased risk of another abnormality, including cardiac defects. The presence of a soft marker is not diagnostic of this other abnormality; it is just a noted association.

At the time of the sonogram, therefore, you can only suspect a problem with the fetal genes; further testing is required. In that case, report 655.13 (known or suspected chromosomal abnormality of the fetus affecting management of mother; antepartum condition or complication) with a secondary diagnosis of 793.99 (other nonspecific abnormal findings on radiological and other examinations of body structure).

Positive ANA—don’t leap to “autoimmune disorder”

Q. One of our obstetric patients had a positive antinuclear antibody (ANA) test. We‘ll follow her with biophysical profiles and non-stress testing, and track amniotic fluid volume. Because we have not yet diagnosed systemic lupus erythematosus (SLE) or other specific condition, is it appropriate to use a diagnosis of unspecified autoimmune disorder (279.4) in addition to a pregnancy complication code?

A. Many illnesses and conditions are associated with a positive ANA, including rheumatoid arthritis, Sjögren syndrome, scleroderma, and SLE; infectious diseases such as mononucleosis; and autoimmune thyroid and liver disease. Some medications can cause a positive ANA, and many healthy people have a positive ANA.

Because you have not eliminated the other possibilities for the positive ANA, it is premature to assign the code for an autoimmune condition. Instead, report 648.93 as your primary code (Other current conditions in the mother classifiable elsewhere, complicating pregnancy, childbirth, or the puerperium; antepartum condition or complication), with the secondary diagnosis code 795.79 (Other and unspecified nonspecific immunological findings).

Coding Zoladex depends on the patient’s condition

Q. We have begun using Zoladex for our patients. How do we best code for administering this agent? We have been told to use chemotherapy codes, but this is not a chemotherapeutic agent.

A. Zoladex (goserelin acetate) is classified as a hormonal antineoplastic. It is used to treat endometriosis before surgery because it thins the lining of the uterus, and to treat breast cancer by inhibiting production of estrogen.

The drug is supplied as tiny pellets, which are injected under the skin of the abdomen using a small, “trocar-like” needle and syringe. The procedure constitutes an injection. If you are treating breast cancer with this drug, the correct code would be 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic). The code for the pellets is J9202 (Goserelin acetate implant, per 3.6 mg). If you administer more than 3.6 mg at a time, remember to adjust the quantity you bill for. If you are using this drug to treat endometriosis or fibroids, CPT directs you to report 90772 for the injection because it is then considered a nonantineoplastic hormone injection.

Call a contraceptive a contraceptive when coding

Q. How should we code for Implanon insertions?

A. Code this S0180 (Etonogestrel [contraceptive] implant system, including implants and supplies). For the procedure, I recommend code 11975 (insertion, implantable contraceptive capsules).

Implanon’s manufacturer thinks the correct code is 11981 (Insertion, nonbiodegradable drug delivery implant), but I disagree: This is a contraceptive that is implanted under the skin and, under CPT rules, you must use the code that most closely describes the procedure.

 

Note also that, although Implanon involves insertion of one rod (other systems require insertion of several), the code 11981 has greater relative value units than 11975. This payment difference will not be lost on most payers because the diagnostic link for the procedure, whichever code is reported, is V25.5 (insertion of implantable subdermal contraceptive).

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

Is it “major” or “minor” dehiscence repair?

Q. I examined a patient at a routine postop visit and noticed that the surgical wound had split open. I brought her back into surgery the next day to repair the wound. Can I bill the postoperative visit in addition to the surgery if I attach a modifier -57?

A. CPT doesn’t have a hard and fast rule on this situation. But a modifier -57 (Decision for surgery) is generally reserved for more extensive evaluation of a patient whose problem results in a decision to do major surgery that day or the next. (“Major surgery” is any surgery that has a 90-day global period.)

You have 2 code choices. Surgery to repair wound dehiscence (Diagnosis code 998.32, Disruption of external operation wound) would be reported with:

• code 12020 (Treatment of superficial wound dehiscence; simple closure), which has a global period of 10 days, or
  
• code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.
  

Because the visit was scheduled as routine—by which I mean it appears that the patient did not realize there was a problem with the wound—it may be that you performed only a simple closure. In that case, it would be inappropriate to use a modifier -57. You should, however, add a modifier -78 (Return to the operating room for a related procedure during the postoperative period) to code 12020.

If, instead, dehiscence involved complex repair and you documented significant evaluation above and beyond normal postoperative care before determining that repair was necessary, you may bill that level of service with a modifier -57.

No new code for new Depo-Provera formulation

Q. Our practice has decided to purchase the new depo-subQ provera 104 (medroxyprogesterone acetate, 104 mg) for injection. Our coding staff can’t find a code for this product. Can you help?

A. Normally, you would report injection using a Healthcare Common Procedure Coding System (HCPCS) “J” code, but there is no code for this new product yet. That leaves you with 3 coding options:

• Report J3490 (Unclassified drug), but also submit the National Drug Code (NDC) number to identify the injection
  
• Report 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and be sure to indicate the NDC number
  
• Report the existing code for a noncontraceptive dosage of Depo-Provera (J1051) multiplied by a quantity of 2 (J1051 is for a 50-mg dosage).
  

I recommend that you use the last option only if the payer insists that you submit a “J” code for injection but will not accept the “J” code for an unclassified drug.

Co-surgery: Both surgeons bill, with modifier

Q. I was called in to provide intraoperative consultation for a neighboring general surgeon. He had performed an exploratory laparotomy, and the only finding was a pedunculated fibroid. I performed a myomectomy, assisted by the general surgeon. He had begun the procedure with his physician assistant and finished assisted by the PA after I finished my part. What is the best way to code for this situation?

A. Under CPT guidelines that were clarified in the American Medical Association’s May 1997 “CPT Assistant,” this is a co-surgery case because (1) establishing the operative site and exploration are integral to the procedure and (2) you both performed a distinct part of the procedure. You and the general surgeon would use the same surgical code with a modifier -62 [Two surgeons]. Your code choice for this procedure would be 58140 [Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach].

The general surgeon should also bill for the surgical assistant services of the PA by adding a modifier AS [Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery] to this same surgical code. Some payers might deny an assistant in a co-surgery case, but the documentation in this situation would support the need because the PA assisted only when you were not present.

Delay doesn’t change coding for surgical tx of incomplete abortion

Q. I recently performed a suction D&C for an incomplete voluntary abortion done 2 months ago that was hemorrhaging and had retained products of conception. Our billing department coded this as 59840, but the payer rejected the claim, stating that they already paid the hospital for 59812, which I thought was reported only for a spontaneous abortion. Should we refile?

A. Yes. At this point, you are removing retained products of conception no matter what the patient intended 2 months ago. This means that you are performing a surgical treatment of an incomplete abortion, coded 59812. Code 59840 implies that you are the one inducing the abortion at this surgical session—not the case.

The diagnosis for bleeding after an abortion performed at a previous surgery is 639.1.

Co-surgery: Both surgeons bill, with modifier

Q. I was called in to provide intraoperative consultation for a neighboring general surgeon. He had performed an exploratory laparotomy, and the only finding was a pedunculated fibroid. I performed a myomectomy, assisted by the general surgeon. He had begun the procedure with his physician assistant and finished assisted by the PA after I finished my part. What is the best way to code for this situation?

A. Under CPT guidelines that were clarified in the American Medical Association’s May 1997 “CPT Assistant,” this is a co-surgery case because (1) establishing the operative site and exploration are integral to the procedure and (2) you both performed a distinct part of the procedure. You and the general surgeon would use the same surgical code with a modifier -62 [Two surgeons]. Your code choice for this procedure would be 58140 [Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach].

The general surgeon should also bill for the surgical assistant services of the PA by adding a modifier AS [Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery] to this same surgical code. Some payers might deny an assistant in a co-surgery case, but the documentation in this situation would support the need because the PA assisted only when you were not present.

Delay doesn’t change coding for surgical tx of incomplete abortion

Q. I recently performed a suction D&C for an incomplete voluntary abortion done 2 months ago that was hemorrhaging and had retained products of conception. Our billing department coded this as 59840, but the payer rejected the claim, stating that they already paid the hospital for 59812, which I thought was reported only for a spontaneous abortion. Should we refile?

A. Yes. At this point, you are removing retained products of conception no matter what the patient intended 2 months ago. This means that you are performing a surgical treatment of an incomplete abortion, coded 59812. Code 59840 implies that you are the one inducing the abortion at this surgical session—not the case.

The diagnosis for bleeding after an abortion performed at a previous surgery is 639.1.

Co-surgery: Both surgeons bill, with modifier

Q. I was called in to provide intraoperative consultation for a neighboring general surgeon. He had performed an exploratory laparotomy, and the only finding was a pedunculated fibroid. I performed a myomectomy, assisted by the general surgeon. He had begun the procedure with his physician assistant and finished assisted by the PA after I finished my part. What is the best way to code for this situation?

A. Under CPT guidelines that were clarified in the American Medical Association’s May 1997 “CPT Assistant,” this is a co-surgery case because (1) establishing the operative site and exploration are integral to the procedure and (2) you both performed a distinct part of the procedure. You and the general surgeon would use the same surgical code with a modifier -62 [Two surgeons]. Your code choice for this procedure would be 58140 [Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach].

The general surgeon should also bill for the surgical assistant services of the PA by adding a modifier AS [Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery] to this same surgical code. Some payers might deny an assistant in a co-surgery case, but the documentation in this situation would support the need because the PA assisted only when you were not present.

Delay doesn’t change coding for surgical tx of incomplete abortion

Q. I recently performed a suction D&C for an incomplete voluntary abortion done 2 months ago that was hemorrhaging and had retained products of conception. Our billing department coded this as 59840, but the payer rejected the claim, stating that they already paid the hospital for 59812, which I thought was reported only for a spontaneous abortion. Should we refile?

A. Yes. At this point, you are removing retained products of conception no matter what the patient intended 2 months ago. This means that you are performing a surgical treatment of an incomplete abortion, coded 59812. Code 59840 implies that you are the one inducing the abortion at this surgical session—not the case.

The diagnosis for bleeding after an abortion performed at a previous surgery is 639.1.

Multisite injection might not be reimbursed as multiple procedures

Q. I have been injecting lidocaine in a grid pattern into the vulvar area of some of my patients to treat vestibulitis. Is there a specific CPT code for this procedure?

A. Although CPT includes codes for injection into nerves [eg, 64430, Injection, anesthetic agent; pudendal nerve], lesions [eg, 11900, Injection, intralesional; up to and including seven lesions], and trigger-point muscles [eg, 20552, Injection(s); single or multiple trigger point(s), one or two muscle(s)], it appears that the local anesthetic you are injecting is being placed subcutaneously. This means that code 90772 [Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular] is the correct code.

What may present a problem, however, is that you are administering lidocaine in several areas of the vulva. Many payers have a unit limitation for the number of injections you can bill at one time; if you use the same syringe and needle for injection at multiple sites, the payer may decide to reimburse for only a single injection.

Some practices have been successful in getting fair reimbursement by billing code 58999 [Unlisted procedure, female genital system (nonobstetrical)] for this treatment.

If you will be billing the injection procedure instead, note that the “J” code for lidocaine was deleted in 2006. To bill for lidocaine, report J3490 [Unclassified drugs]. Lidocaine would be included as a supply with code 58999 and therefore not separately billable.

Split preop visit from surgery? Maybe

Q. When a procedure (such as hysteroscopy) has no global days and the decision to perform the surgery was made at a previous visit (perhaps days or weeks before the procedure), can we bill a preoperative visit that is made the week of the surgery? This visit involves talking to the patient to answer any additional questions, taking a history and performing a physical exam, providing preadmission and preoperative instructions, and having her sign the informed consent form.

A. There isn’t any black-and-white answer; the payer determines the coverage. Many payers consider the service that you are describing integral to performing any surgery and therefore included in the billing for the procedure—especially if the visit occurred within 48 hours before planned surgery.

Some payers will reimburse for this visit, however, and you owe it to them to indicate the nature of the visit. This means that you should not provide a diagnosis code for the visit that is the actual reason for doing the surgery; instead, code V72.83 [other specified preop exam] or V72.84 [unspecified preop exam]. This allows the payer to apply its policy on this matter. A payer that includes the preop exam will deny the claim; one that doesn’t, will reimburse you.

Multisite injection might not be reimbursed as multiple procedures

Q. I have been injecting lidocaine in a grid pattern into the vulvar area of some of my patients to treat vestibulitis. Is there a specific CPT code for this procedure?

A. Although CPT includes codes for injection into nerves [eg, 64430, Injection, anesthetic agent; pudendal nerve], lesions [eg, 11900, Injection, intralesional; up to and including seven lesions], and trigger-point muscles [eg, 20552, Injection(s); single or multiple trigger point(s), one or two muscle(s)], it appears that the local anesthetic you are injecting is being placed subcutaneously. This means that code 90772 [Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular] is the correct code.

What may present a problem, however, is that you are administering lidocaine in several areas of the vulva. Many payers have a unit limitation for the number of injections you can bill at one time; if you use the same syringe and needle for injection at multiple sites, the payer may decide to reimburse for only a single injection.

Some practices have been successful in getting fair reimbursement by billing code 58999 [Unlisted procedure, female genital system (nonobstetrical)] for this treatment.

If you will be billing the injection procedure instead, note that the “J” code for lidocaine was deleted in 2006. To bill for lidocaine, report J3490 [Unclassified drugs]. Lidocaine would be included as a supply with code 58999 and therefore not separately billable.

Split preop visit from surgery? Maybe

Q. When a procedure (such as hysteroscopy) has no global days and the decision to perform the surgery was made at a previous visit (perhaps days or weeks before the procedure), can we bill a preoperative visit that is made the week of the surgery? This visit involves talking to the patient to answer any additional questions, taking a history and performing a physical exam, providing preadmission and preoperative instructions, and having her sign the informed consent form.

A. There isn’t any black-and-white answer; the payer determines the coverage. Many payers consider the service that you are describing integral to performing any surgery and therefore included in the billing for the procedure—especially if the visit occurred within 48 hours before planned surgery.

Some payers will reimburse for this visit, however, and you owe it to them to indicate the nature of the visit. This means that you should not provide a diagnosis code for the visit that is the actual reason for doing the surgery; instead, code V72.83 [other specified preop exam] or V72.84 [unspecified preop exam]. This allows the payer to apply its policy on this matter. A payer that includes the preop exam will deny the claim; one that doesn’t, will reimburse you.

Multisite injection might not be reimbursed as multiple procedures

Q. I have been injecting lidocaine in a grid pattern into the vulvar area of some of my patients to treat vestibulitis. Is there a specific CPT code for this procedure?

A. Although CPT includes codes for injection into nerves [eg, 64430, Injection, anesthetic agent; pudendal nerve], lesions [eg, 11900, Injection, intralesional; up to and including seven lesions], and trigger-point muscles [eg, 20552, Injection(s); single or multiple trigger point(s), one or two muscle(s)], it appears that the local anesthetic you are injecting is being placed subcutaneously. This means that code 90772 [Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular] is the correct code.

What may present a problem, however, is that you are administering lidocaine in several areas of the vulva. Many payers have a unit limitation for the number of injections you can bill at one time; if you use the same syringe and needle for injection at multiple sites, the payer may decide to reimburse for only a single injection.

Some practices have been successful in getting fair reimbursement by billing code 58999 [Unlisted procedure, female genital system (nonobstetrical)] for this treatment.

If you will be billing the injection procedure instead, note that the “J” code for lidocaine was deleted in 2006. To bill for lidocaine, report J3490 [Unclassified drugs]. Lidocaine would be included as a supply with code 58999 and therefore not separately billable.

Split preop visit from surgery? Maybe

Q. When a procedure (such as hysteroscopy) has no global days and the decision to perform the surgery was made at a previous visit (perhaps days or weeks before the procedure), can we bill a preoperative visit that is made the week of the surgery? This visit involves talking to the patient to answer any additional questions, taking a history and performing a physical exam, providing preadmission and preoperative instructions, and having her sign the informed consent form.

A. There isn’t any black-and-white answer; the payer determines the coverage. Many payers consider the service that you are describing integral to performing any surgery and therefore included in the billing for the procedure—especially if the visit occurred within 48 hours before planned surgery.

Some payers will reimburse for this visit, however, and you owe it to them to indicate the nature of the visit. This means that you should not provide a diagnosis code for the visit that is the actual reason for doing the surgery; instead, code V72.83 [other specified preop exam] or V72.84 [unspecified preop exam]. This allows the payer to apply its policy on this matter. A payer that includes the preop exam will deny the claim; one that doesn’t, will reimburse you.

Avoid confusion over terms when billing McCall culdoplasty

Q I performed a McCall culdoplasty following vaginal hysterectomy, but the insurance company denied payment for the culdoplasty, stating that this procedure is included in the hysterectomy. How do I appeal?

ADenial could take place only if the incorrect code combination was billed. For example, if your billing staff itemized the procedures by reporting 58260 for the vaginal hysterectomy and 57268 [Repair of enterocele, vaginal approach (separate procedure)], then the enterocele repair (McCall) would be denied as inclusive, as these two codes are bundled. But they are bundled because there are 4 codes that combine enterocele repair with vaginal hysterectomy, depending on the documented weight of the uterus and whether you took, or left, the tubes and ovaries.

Your code choices are:

58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele

58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele

58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele

58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

Don’t blame your billing staff if this is what occurred. The term “McCall culdoplasty” appears nowhere in the CPT book, so your billers would need to know that you actually performed an enterocele repair.

Correctly communicating what you did is an important step in getting the claim paid in a timely manner. Refile with the correct code!

Read a description of the technique of McCall culdoplasty.

Complete and transvaginal US scan must be specified

Q Regarding ultrasonography (US) codes 76856 and 76857, are these codes for an abdominal or a vaginal approach? Recently, we scanned a patient transvaginally for a complete US study (uterine, ovary, stripe, etc) but could not determine which code to use. My understanding has been that code 76830 is for a limited transvaginal scan.

ACodes 76856 [Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete] and 76857 [Ultrasound…; limited or follow-up (eg, for follicles)] describe a transabdominal approach. If you performed a complete transvaginal scan, the code would be 76830, which is not a limited scan. In fact, the physician work relative value units assigned to these codes are identical, at .69. The only code for a limited gynecologic US would be 76857. If you performed a limited US by a vaginal approach, however, you can bill 76830 with a modifier -52 (reduced services) added to indicate that you did not perform a complete scan.

Avoid confusion over terms when billing McCall culdoplasty

Q I performed a McCall culdoplasty following vaginal hysterectomy, but the insurance company denied payment for the culdoplasty, stating that this procedure is included in the hysterectomy. How do I appeal?

ADenial could take place only if the incorrect code combination was billed. For example, if your billing staff itemized the procedures by reporting 58260 for the vaginal hysterectomy and 57268 [Repair of enterocele, vaginal approach (separate procedure)], then the enterocele repair (McCall) would be denied as inclusive, as these two codes are bundled. But they are bundled because there are 4 codes that combine enterocele repair with vaginal hysterectomy, depending on the documented weight of the uterus and whether you took, or left, the tubes and ovaries.

Your code choices are:

58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele

58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele

58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele

58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

Don’t blame your billing staff if this is what occurred. The term “McCall culdoplasty” appears nowhere in the CPT book, so your billers would need to know that you actually performed an enterocele repair.

Correctly communicating what you did is an important step in getting the claim paid in a timely manner. Refile with the correct code!

Read a description of the technique of McCall culdoplasty.

Complete and transvaginal US scan must be specified

Q Regarding ultrasonography (US) codes 76856 and 76857, are these codes for an abdominal or a vaginal approach? Recently, we scanned a patient transvaginally for a complete US study (uterine, ovary, stripe, etc) but could not determine which code to use. My understanding has been that code 76830 is for a limited transvaginal scan.

ACodes 76856 [Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete] and 76857 [Ultrasound…; limited or follow-up (eg, for follicles)] describe a transabdominal approach. If you performed a complete transvaginal scan, the code would be 76830, which is not a limited scan. In fact, the physician work relative value units assigned to these codes are identical, at .69. The only code for a limited gynecologic US would be 76857. If you performed a limited US by a vaginal approach, however, you can bill 76830 with a modifier -52 (reduced services) added to indicate that you did not perform a complete scan.

Avoid confusion over terms when billing McCall culdoplasty

Q I performed a McCall culdoplasty following vaginal hysterectomy, but the insurance company denied payment for the culdoplasty, stating that this procedure is included in the hysterectomy. How do I appeal?

ADenial could take place only if the incorrect code combination was billed. For example, if your billing staff itemized the procedures by reporting 58260 for the vaginal hysterectomy and 57268 [Repair of enterocele, vaginal approach (separate procedure)], then the enterocele repair (McCall) would be denied as inclusive, as these two codes are bundled. But they are bundled because there are 4 codes that combine enterocele repair with vaginal hysterectomy, depending on the documented weight of the uterus and whether you took, or left, the tubes and ovaries.

Your code choices are:

58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele

58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele

58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele

58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

Don’t blame your billing staff if this is what occurred. The term “McCall culdoplasty” appears nowhere in the CPT book, so your billers would need to know that you actually performed an enterocele repair.

Correctly communicating what you did is an important step in getting the claim paid in a timely manner. Refile with the correct code!

Read a description of the technique of McCall culdoplasty.

Complete and transvaginal US scan must be specified

Q Regarding ultrasonography (US) codes 76856 and 76857, are these codes for an abdominal or a vaginal approach? Recently, we scanned a patient transvaginally for a complete US study (uterine, ovary, stripe, etc) but could not determine which code to use. My understanding has been that code 76830 is for a limited transvaginal scan.

ACodes 76856 [Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete] and 76857 [Ultrasound…; limited or follow-up (eg, for follicles)] describe a transabdominal approach. If you performed a complete transvaginal scan, the code would be 76830, which is not a limited scan. In fact, the physician work relative value units assigned to these codes are identical, at .69. The only code for a limited gynecologic US would be 76857. If you performed a limited US by a vaginal approach, however, you can bill 76830 with a modifier -52 (reduced services) added to indicate that you did not perform a complete scan.