Melanie Witt, RN, CPC, COBGC, MA

This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.

On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.

In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.

In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.

Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.

The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!

Changes to obstetric codes

PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY

Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.

For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.

Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.

Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.

The new codes for a twin pregnancy are:

V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs

V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)

V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)

V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)

V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs

There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).

RECURRENT PREGNANCY LOSS

The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:

629.81 Recurrent pregnancy loss without current pregnancy

646.3x Recurrent pregnancy loss (affecting the current pregnancy)

INDEX AND INSTRUCTIONAL CHANGES

These OB changes took effect on October 1, 2010:

• Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
• If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
• If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
• If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
• If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).

Changes to gyn codes

CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA

Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.

Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).

A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.

Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:

752.31 Agenesis of uterus

752.32 Hypoplasia of uterus

752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)

752.34 Bicornuate uterus

752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)

752.36 Arcuate uterus

752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)

New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.

752.43 Cervical agenesis

752.44 Cervical duplication

752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)

752.46 Transverse vaginal septum

752.47 Longitudinal vaginal septum

For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.

IUD INSERTION AND REMOVAL

Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.

Changes in this area are:

Before October 1, 2010:

V25.1 Insertion

V25.42 Checking, reinsertion and/or removal After October 1, 2010:

V25.11 Encounter for insertion of intrauterine contraceptive device

V25.12 Encounter for removal of intrauterine contraceptive device

V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device

V25.42 Encounter for routine checking of intrauterine contraceptive device

BODY MASS INDEX

Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.

Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).

V85.41 Body Mass Index 40.0–44.9, adult

V85.42 Body Mass Index 45.0–49.9, adult

V85.43 Body Mass Index 50.0–59.9, adult

V85.44 Body Mass Index 60.0–69.9, adult

V85.45 Body Mass Index 70 and over, adult

FECAL INCONTINENCE

Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.

For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.

New codes are:

560.32 Fecal impaction

787.60 Full incontinence of feces

787.61 Incomplete defecation

787.62 Fecal smearing

787.63 Fecal urgency

PERSONAL HISTORY OF DYSPLASIA

New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:

V13.23 Personal history of vaginal dysplasia

V13.34 Personal history of vulvar dysplasia

INDEX AND INSTRUCTIONAL CHANGES

These changes take effect October 1, 2010:

• Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
• Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
• Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
• The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.

We want to hear from you! Tell us what you think.

This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.

On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.

In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.

In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.

Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.

The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!

Changes to obstetric codes

PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY

Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.

For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.

Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.

Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.

The new codes for a twin pregnancy are:

V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs

V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)

V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)

V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)

V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs

There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).

RECURRENT PREGNANCY LOSS

The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:

629.81 Recurrent pregnancy loss without current pregnancy

646.3x Recurrent pregnancy loss (affecting the current pregnancy)

INDEX AND INSTRUCTIONAL CHANGES

These OB changes took effect on October 1, 2010:

• Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
• If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
• If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
• If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
• If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).

Changes to gyn codes

CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA

Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.

Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).

A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.

Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:

752.31 Agenesis of uterus

752.32 Hypoplasia of uterus

752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)

752.34 Bicornuate uterus

752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)

752.36 Arcuate uterus

752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)

New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.

752.43 Cervical agenesis

752.44 Cervical duplication

752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)

752.46 Transverse vaginal septum

752.47 Longitudinal vaginal septum

For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.

IUD INSERTION AND REMOVAL

Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.

Changes in this area are:

Before October 1, 2010:

V25.1 Insertion

V25.42 Checking, reinsertion and/or removal After October 1, 2010:

V25.11 Encounter for insertion of intrauterine contraceptive device

V25.12 Encounter for removal of intrauterine contraceptive device

V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device

V25.42 Encounter for routine checking of intrauterine contraceptive device

BODY MASS INDEX

Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.

Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).

V85.41 Body Mass Index 40.0–44.9, adult

V85.42 Body Mass Index 45.0–49.9, adult

V85.43 Body Mass Index 50.0–59.9, adult

V85.44 Body Mass Index 60.0–69.9, adult

V85.45 Body Mass Index 70 and over, adult

FECAL INCONTINENCE

Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.

For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.

New codes are:

560.32 Fecal impaction

787.60 Full incontinence of feces

787.61 Incomplete defecation

787.62 Fecal smearing

787.63 Fecal urgency

PERSONAL HISTORY OF DYSPLASIA

New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:

V13.23 Personal history of vaginal dysplasia

V13.34 Personal history of vulvar dysplasia

INDEX AND INSTRUCTIONAL CHANGES

These changes take effect October 1, 2010:

• Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
• Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
• Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
• The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.

We want to hear from you! Tell us what you think.

This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.

On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.

In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.

In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.

Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.

The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!

Changes to obstetric codes

PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY

Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.

For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.

Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.

Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.

The new codes for a twin pregnancy are:

V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs

V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)

V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)

V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)

V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs

There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).

RECURRENT PREGNANCY LOSS

The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:

629.81 Recurrent pregnancy loss without current pregnancy

646.3x Recurrent pregnancy loss (affecting the current pregnancy)

INDEX AND INSTRUCTIONAL CHANGES

These OB changes took effect on October 1, 2010:

• Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
• If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
• If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
• If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
• If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).

Changes to gyn codes

CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA

Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.

Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).

A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.

Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:

752.31 Agenesis of uterus

752.32 Hypoplasia of uterus

752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)

752.34 Bicornuate uterus

752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)

752.36 Arcuate uterus

752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)

New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.

752.43 Cervical agenesis

752.44 Cervical duplication

752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)

752.46 Transverse vaginal septum

752.47 Longitudinal vaginal septum

For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.

IUD INSERTION AND REMOVAL

Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.

Changes in this area are:

Before October 1, 2010:

V25.1 Insertion

V25.42 Checking, reinsertion and/or removal After October 1, 2010:

V25.11 Encounter for insertion of intrauterine contraceptive device

V25.12 Encounter for removal of intrauterine contraceptive device

V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device

V25.42 Encounter for routine checking of intrauterine contraceptive device

BODY MASS INDEX

Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.

Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).

V85.41 Body Mass Index 40.0–44.9, adult

V85.42 Body Mass Index 45.0–49.9, adult

V85.43 Body Mass Index 50.0–59.9, adult

V85.44 Body Mass Index 60.0–69.9, adult

V85.45 Body Mass Index 70 and over, adult

FECAL INCONTINENCE

Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.

For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.

New codes are:

560.32 Fecal impaction

787.60 Full incontinence of feces

787.61 Incomplete defecation

787.62 Fecal smearing

787.63 Fecal urgency

PERSONAL HISTORY OF DYSPLASIA

New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:

V13.23 Personal history of vaginal dysplasia

V13.34 Personal history of vulvar dysplasia

INDEX AND INSTRUCTIONAL CHANGES

These changes take effect October 1, 2010:

• Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
• Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
• Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
• The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.

We want to hear from you! Tell us what you think.

Current Procedural Terminology (CPT) 2010, which took effect January 1, doesn’t bring many changes for ObGyn practice, but there’s been a major backpedaling in Medicare coverage of consultations that you must be aware of. In conjunction with this move by the Centers for Medicare & Medicaid Services (CMS), CPT has added a definition of “transfer of care” and established two possible reasons for providing a consultation. I’ll have more to report about these important developments later in this article.

Among the changes to billing codes for the work performed in ObGyn: rebundling of commonly performed urodynamics procedures and new codes for revision of a vaginal graft. There is also a new (and unpublished) code for administering the H1N1 influenza vaccine.

Last, CPT has revised the explanation of non–face-to-face prolonged services. Read on!

New codes bundle urodynamic studies—a product of joint CMS and CPT input

The biggest changes in coding for ObGyn procedures are urodynamics study codes. The American Medical Association (AMA) has 1) created three new codes that represent test bundles and, in the process, 2) deleted the stand-alone urodynamics codes 51772 (urethral pressure profile studies [UPP] [urethral closure pressure profile], any technique) and 51795 (voiding pressure studies; bladder voiding pressure, any technique).

These changes were made because the most commonly reported codes for a female patient were billed together 90% of the time (51726, 51772, 51795, and 51797); the AMA reasoned that the most frequent combinations were considered overvalued when billed separately—that is, there was no repeat of pre-test and post-test work when these combinations were performed and there was no duplication in the cost of supplies and staff time.

The new bundles were therefore considered to better reflect current medical practice, and the Relative Value Update Committee (RUC) recommended, and CMS accepted, the relative value units (RVU) for the combination codes to reflect the true physician work value and practice expense of the combined procedures.

New and revised codes are:

51726 Complex cystometrogram (i.e., calibrated electronic equipment)

51727 …with urethral pressure profile studies (i.e., urethral closure pressure profile), any technique

51728 …with voiding pressure studies (i.e., bladder voiding pressure), any technique

51729 …with voiding pressure studies (i.e., bladder voiding pressure) and urethral pressure profile studies (i.e., urethral closure pressure profile), any technique.

According to the clinical vignette submitted to the AMA for code 51727, this procedure will include a sustained Valsalva maneuver as part of the urethral closure pressure profile. CPT did, however, retain the add-on code +51797 (voiding pressure studies, intra-abdominal [i.e., rectal, gastric, intraperitoneal]) and has clarified that 51797 may be billed in addition to 51728 and 51729 if a rectal catheter is placed to determine if the patient is straining during the voiding event.

In other words, the add-on code may be reported only when the primary procedure includes a voiding pressure study.

RVU for these new procedures have also been revised (see the TABLE ). Notable is the seeming discrepancy in RVU between code 51726 (cystometrogram alone) and the bundled tests. This is the case because the practice expense for 51726 has not reached its final level (the practice expense RVU are being increased or decreased in increments over several years); for 2010 only, therefore, this code will have a higher total RVU value than the new codes (51727, 51728, 51729), despite having a lower physician work relative value.

The discrepancy will be corrected in 2011, when 51726 will have lower RVU than the other urodynamics combination test codes.

TABLE

Changes in 2010 to RVU for urodynamic studies

Laparoscopic revision of a vaginal graft

In 2006, the AMA added the code for a vaginal approach to revising a graft (57295, revision [including removal] of prosthetic vaginal graft; vaginal approach). Then, in 2007, it added a code for an abdominal approach (57296, revision [including removal] of prosthetic vaginal graft; open abdominal approach).

Now, you have a code for a laparoscopic approach, completing the code set for this procedure. As with 57295 and 57296, report the new code when the graft is either revised or removed entirely.

57426 Revision (including removal) of prosthetic vaginal graft, laparoscopic approach

Other, miscellaneous changes take effect

OBSTETRIC PANEL

Although code 80055 comprises a battery of tests that are performed routinely on obstetric patients, a new code, 86780, was created to report syphilis screening using a treponemal antibody method, in which IgM and IgG antibodies are measured. This test is not the same syphilis test that is now part of the 80055 panel. CPT has therefore cautioned that, when you use code 86780 instead of the standard syphilis test code 86592, you should not report the obstetrics panel but, instead, separately report each test performed.

REPRODUCTIVE MEDICINE

New code 89398 (unlisted reproductive medicine laboratory procedure) has been added, but CPT still directs billers to use the unlisted miscellaneous pathology test code 89240 to report cryopreservation of reproductive ovarian tissues.

BILLING FOR THE H1N1 INFLUENZA VACCINE

Because of the urgency of collecting data on the H1N1 influenza epidemic, CPT has revised code 90663 to include the H1N1 formulation of the flu vaccine product. In addition, CPT has created a new code, 90470, for administering the H1N1 flu vaccine, which became valid in September (but which isn’t included in the hard-copy version of CPT 2010). The new code is to be used for intramuscular injection or intranasal administration, and includes any time spent counseling.

In addition:

• Do not report established code 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) when you administer the H1N1 flu vaccine
• Report the vaccine product code only when your practice has purchased the vaccine, or when the payer requires the code with a 0 charge to match the administration code.
• Medicare coding for administering the H1N1 flu vaccine is different than what I’ve just described. Do not use CPT codes for Medicare patients; instead, code H1N1 flu immunization as:

G9141 Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

G9142 Influenza A (H1N1) vaccine, any route of administration

Medicare will not reimburse for the vaccine product because it is being given to its providers without cost. Some carriers may require that the new vaccine product code be listed with a 0 charge.

Prolonged inpatient E/M services

CPT has revised guidelines for prolonged services that do not involve direct face-to-face contact with a patient. Keep in mind, however, that, although these changes are welcome, many payers don’t reimburse separately for work that isn’t performed face to face.

These codes are no longer considered add-on codes; they can be reported on a different date than the related E/M service.

According to CPT, codes 99358 and 99359 are reported when the prolonged time:

• is greater than would be expected for normal pre-service and post-service work associated with the E/M service
• exceeds 30 minutes
• is related to an E/M service that has already occurred, or to one that will occur and represents ongoing patient management (for example, your review of extensive patient records that weren’t available at the time of the visit)
• is in addition to any telephone services codes (99441–99443)—but not with more specific codes, such as medical team conferences, online medical evaluation, or care plan oversight services, which have no upper limit to the time required to accomplish the service.

Consultation codes and clarifications

Two changes of note, from a CPT perspective, have been made in the area of consultations. CPT has:

• added a definition for a transfer of care
• defined two circumstances under which a consultation can be coded. These revisions come at the same time Medicare has made the decision to no longer pay for consultations other than tele-health consults (see following section).

For 2010, CPT defines transfer of care as

…the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services.

The guidelines also explain that 1) a transferring physician is no longer responsible for caring for the problem for which the patient was referred and 2) the consultation codes should not be reported by the physician who accepts care.

Two alternative conditions must now apply for a consultation to be considered provided:

• A physician requested an opinion or advice for a specific condition or problem, or
• The consulting physician saw the patient first to determine whether to accept ongoing management of her entire care or of a specific condition or problem (i.e., transfer of care).

The second condition is new; it remains to be seen if payers will accept it as a valid reason to bill for consultation.

As with all billable services, you should ensure that the criteria required by the payer you are billing have been met. CPT also directs that the written request for consultation can be documented by either the requesting or the receiving physician—something that was unacceptable under Medicare guidelines.

Last, CPT has added instructions to clarify the type of consultation code to bill under certain circumstances:

• When the patient is admitted after an outpatient consultation but the physician does not see the patient on the unit on the date of admission, bill only for outpatient consultation
• When the patient is seen for an office visit, emergency room visit, or outpatient consult on the date of admission and the physician then sees the patient on the unit that day, bill only the inpatient consultation or initial hospital care code, whichever applies. All services that day are used to determine the final level of service.

Medicare tilts the playing field on consultations

Although CPT has retained all consultation codes, and although the hope is that commercial payers will continue to reimburse for such services in the near future, the big news is that Medicare has announced that it will no longer recognize (or reimburse for) codes for outpatient or inpatient consultations. (Note: This story is still unfolding, however. The changes announced by Medicare that I discuss below are still before Congress as this article goes to press. Although Medicare has, in fact, released the transmittal letter to all carriers instructing them about the changes, Senator Arlen Specter [D-Pa] has introduced an amendment to the Patient Protection and Affordable Care Act [H.R. 3590] to postpone the policy change for 1 year. If Congress has not passed this bill before the end of 2009, the changes go through as planned. Stay tuned for developments!)

Assuming the changes go through, here is what is expected of you in the circumstances of providing consultations and billing Medicare (Medicaid payers aren’t required to follow this policy change but may opt to do so).

Outpatients. Document, and report, the appropriate level of visit for a new or established Medicare patient using outpatient codes 99201–99215

Inpatients. If you are a non-admitting physician asked to see a patient for the first time, report the appropriate level of initial hospital care (codes 99221–99223). Note the following three points:

• Initial hospital care includes only three levels of service—not the five levels from which you choose for consultation codes
• The lowest level of history and exam for these initial visit codes is a detailed history and examination—no matter the level of medical decision-making. If the level of history or exam is documented lower than “detailed”—say, as “expanded problem-focused”—you are required to report the unlisted E/M code 99499.
• The admitting physician adds the new Healthcare Common Procedure Coding System (HCPCS) modifier –AI (that is, “‘A’ upper-case ‘i’”) to the initial visit code, so that Medicare can distinguish the admitting physician from others providing care for the patient.
• All subsequent visits with the inpatient continue to be billed with the subsequent care inpatient codes (99231–99233).

Fallout from this change? Medicare is studying the implications of its new policy on secondary payments—that is, when Medicare is the primary payer and there is a supplemental carrier, or when Medicare is the secondary payer. Note: Medicare strongly advises all providers to check with their primary payers, because 1) Medicare will not accept a consultation code when a primary insurer has paid on that code and 2) it’s doubtful that a commercial payer will accept a consultation code when Medicare has paid for a new or established patient service.

To add to the turmoil…

The CMS has announced that, as a result of the changes in Medicare policy on consultations, it is increasing the relative values for all new and established patient services and initial hospital care. CMS is doing this, however, by reducing the relative values of some consultation codes.

In addition, all surgical procedure codes that carry a 10- or 90-day global period will see an increase in work RVU because of the increase in E/M services that are a part of all global care. Keep in mind that payers who use the Resource-Based Relative Value Scale (RBRVS) to reimburse services will probably adopt the new values when contracts are up for renewal, although many will be unable to do so in the short term.

It also remains to be seen if any commercial payers adopt Medicare policy or continue to pay for consultations. This area might be a contract issue with payers.

Current Procedural Terminology (CPT) 2010, which took effect January 1, doesn’t bring many changes for ObGyn practice, but there’s been a major backpedaling in Medicare coverage of consultations that you must be aware of. In conjunction with this move by the Centers for Medicare & Medicaid Services (CMS), CPT has added a definition of “transfer of care” and established two possible reasons for providing a consultation. I’ll have more to report about these important developments later in this article.

Among the changes to billing codes for the work performed in ObGyn: rebundling of commonly performed urodynamics procedures and new codes for revision of a vaginal graft. There is also a new (and unpublished) code for administering the H1N1 influenza vaccine.

Last, CPT has revised the explanation of non–face-to-face prolonged services. Read on!

New codes bundle urodynamic studies—a product of joint CMS and CPT input

The biggest changes in coding for ObGyn procedures are urodynamics study codes. The American Medical Association (AMA) has 1) created three new codes that represent test bundles and, in the process, 2) deleted the stand-alone urodynamics codes 51772 (urethral pressure profile studies [UPP] [urethral closure pressure profile], any technique) and 51795 (voiding pressure studies; bladder voiding pressure, any technique).

These changes were made because the most commonly reported codes for a female patient were billed together 90% of the time (51726, 51772, 51795, and 51797); the AMA reasoned that the most frequent combinations were considered overvalued when billed separately—that is, there was no repeat of pre-test and post-test work when these combinations were performed and there was no duplication in the cost of supplies and staff time.

The new bundles were therefore considered to better reflect current medical practice, and the Relative Value Update Committee (RUC) recommended, and CMS accepted, the relative value units (RVU) for the combination codes to reflect the true physician work value and practice expense of the combined procedures.

New and revised codes are:

51726 Complex cystometrogram (i.e., calibrated electronic equipment)

51727 …with urethral pressure profile studies (i.e., urethral closure pressure profile), any technique

51728 …with voiding pressure studies (i.e., bladder voiding pressure), any technique

51729 …with voiding pressure studies (i.e., bladder voiding pressure) and urethral pressure profile studies (i.e., urethral closure pressure profile), any technique.

According to the clinical vignette submitted to the AMA for code 51727, this procedure will include a sustained Valsalva maneuver as part of the urethral closure pressure profile. CPT did, however, retain the add-on code +51797 (voiding pressure studies, intra-abdominal [i.e., rectal, gastric, intraperitoneal]) and has clarified that 51797 may be billed in addition to 51728 and 51729 if a rectal catheter is placed to determine if the patient is straining during the voiding event.

In other words, the add-on code may be reported only when the primary procedure includes a voiding pressure study.

RVU for these new procedures have also been revised (see the TABLE ). Notable is the seeming discrepancy in RVU between code 51726 (cystometrogram alone) and the bundled tests. This is the case because the practice expense for 51726 has not reached its final level (the practice expense RVU are being increased or decreased in increments over several years); for 2010 only, therefore, this code will have a higher total RVU value than the new codes (51727, 51728, 51729), despite having a lower physician work relative value.

The discrepancy will be corrected in 2011, when 51726 will have lower RVU than the other urodynamics combination test codes.

TABLE

Changes in 2010 to RVU for urodynamic studies

Laparoscopic revision of a vaginal graft

In 2006, the AMA added the code for a vaginal approach to revising a graft (57295, revision [including removal] of prosthetic vaginal graft; vaginal approach). Then, in 2007, it added a code for an abdominal approach (57296, revision [including removal] of prosthetic vaginal graft; open abdominal approach).

Now, you have a code for a laparoscopic approach, completing the code set for this procedure. As with 57295 and 57296, report the new code when the graft is either revised or removed entirely.

57426 Revision (including removal) of prosthetic vaginal graft, laparoscopic approach

Other, miscellaneous changes take effect

OBSTETRIC PANEL

Although code 80055 comprises a battery of tests that are performed routinely on obstetric patients, a new code, 86780, was created to report syphilis screening using a treponemal antibody method, in which IgM and IgG antibodies are measured. This test is not the same syphilis test that is now part of the 80055 panel. CPT has therefore cautioned that, when you use code 86780 instead of the standard syphilis test code 86592, you should not report the obstetrics panel but, instead, separately report each test performed.

REPRODUCTIVE MEDICINE

New code 89398 (unlisted reproductive medicine laboratory procedure) has been added, but CPT still directs billers to use the unlisted miscellaneous pathology test code 89240 to report cryopreservation of reproductive ovarian tissues.

BILLING FOR THE H1N1 INFLUENZA VACCINE

Because of the urgency of collecting data on the H1N1 influenza epidemic, CPT has revised code 90663 to include the H1N1 formulation of the flu vaccine product. In addition, CPT has created a new code, 90470, for administering the H1N1 flu vaccine, which became valid in September (but which isn’t included in the hard-copy version of CPT 2010). The new code is to be used for intramuscular injection or intranasal administration, and includes any time spent counseling.

In addition:

• Do not report established code 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) when you administer the H1N1 flu vaccine
• Report the vaccine product code only when your practice has purchased the vaccine, or when the payer requires the code with a 0 charge to match the administration code.
• Medicare coding for administering the H1N1 flu vaccine is different than what I’ve just described. Do not use CPT codes for Medicare patients; instead, code H1N1 flu immunization as:

G9141 Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

G9142 Influenza A (H1N1) vaccine, any route of administration

Medicare will not reimburse for the vaccine product because it is being given to its providers without cost. Some carriers may require that the new vaccine product code be listed with a 0 charge.

Prolonged inpatient E/M services

CPT has revised guidelines for prolonged services that do not involve direct face-to-face contact with a patient. Keep in mind, however, that, although these changes are welcome, many payers don’t reimburse separately for work that isn’t performed face to face.

These codes are no longer considered add-on codes; they can be reported on a different date than the related E/M service.

According to CPT, codes 99358 and 99359 are reported when the prolonged time:

• is greater than would be expected for normal pre-service and post-service work associated with the E/M service
• exceeds 30 minutes
• is related to an E/M service that has already occurred, or to one that will occur and represents ongoing patient management (for example, your review of extensive patient records that weren’t available at the time of the visit)
• is in addition to any telephone services codes (99441–99443)—but not with more specific codes, such as medical team conferences, online medical evaluation, or care plan oversight services, which have no upper limit to the time required to accomplish the service.

Consultation codes and clarifications

Two changes of note, from a CPT perspective, have been made in the area of consultations. CPT has:

• added a definition for a transfer of care
• defined two circumstances under which a consultation can be coded. These revisions come at the same time Medicare has made the decision to no longer pay for consultations other than tele-health consults (see following section).

For 2010, CPT defines transfer of care as

…the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services.

The guidelines also explain that 1) a transferring physician is no longer responsible for caring for the problem for which the patient was referred and 2) the consultation codes should not be reported by the physician who accepts care.

Two alternative conditions must now apply for a consultation to be considered provided:

• A physician requested an opinion or advice for a specific condition or problem, or
• The consulting physician saw the patient first to determine whether to accept ongoing management of her entire care or of a specific condition or problem (i.e., transfer of care).

The second condition is new; it remains to be seen if payers will accept it as a valid reason to bill for consultation.

As with all billable services, you should ensure that the criteria required by the payer you are billing have been met. CPT also directs that the written request for consultation can be documented by either the requesting or the receiving physician—something that was unacceptable under Medicare guidelines.

Last, CPT has added instructions to clarify the type of consultation code to bill under certain circumstances:

• When the patient is admitted after an outpatient consultation but the physician does not see the patient on the unit on the date of admission, bill only for outpatient consultation
• When the patient is seen for an office visit, emergency room visit, or outpatient consult on the date of admission and the physician then sees the patient on the unit that day, bill only the inpatient consultation or initial hospital care code, whichever applies. All services that day are used to determine the final level of service.

Medicare tilts the playing field on consultations

Although CPT has retained all consultation codes, and although the hope is that commercial payers will continue to reimburse for such services in the near future, the big news is that Medicare has announced that it will no longer recognize (or reimburse for) codes for outpatient or inpatient consultations. (Note: This story is still unfolding, however. The changes announced by Medicare that I discuss below are still before Congress as this article goes to press. Although Medicare has, in fact, released the transmittal letter to all carriers instructing them about the changes, Senator Arlen Specter [D-Pa] has introduced an amendment to the Patient Protection and Affordable Care Act [H.R. 3590] to postpone the policy change for 1 year. If Congress has not passed this bill before the end of 2009, the changes go through as planned. Stay tuned for developments!)

Assuming the changes go through, here is what is expected of you in the circumstances of providing consultations and billing Medicare (Medicaid payers aren’t required to follow this policy change but may opt to do so).

Outpatients. Document, and report, the appropriate level of visit for a new or established Medicare patient using outpatient codes 99201–99215

Inpatients. If you are a non-admitting physician asked to see a patient for the first time, report the appropriate level of initial hospital care (codes 99221–99223). Note the following three points:

• Initial hospital care includes only three levels of service—not the five levels from which you choose for consultation codes
• The lowest level of history and exam for these initial visit codes is a detailed history and examination—no matter the level of medical decision-making. If the level of history or exam is documented lower than “detailed”—say, as “expanded problem-focused”—you are required to report the unlisted E/M code 99499.
• The admitting physician adds the new Healthcare Common Procedure Coding System (HCPCS) modifier –AI (that is, “‘A’ upper-case ‘i’”) to the initial visit code, so that Medicare can distinguish the admitting physician from others providing care for the patient.
• All subsequent visits with the inpatient continue to be billed with the subsequent care inpatient codes (99231–99233).

Fallout from this change? Medicare is studying the implications of its new policy on secondary payments—that is, when Medicare is the primary payer and there is a supplemental carrier, or when Medicare is the secondary payer. Note: Medicare strongly advises all providers to check with their primary payers, because 1) Medicare will not accept a consultation code when a primary insurer has paid on that code and 2) it’s doubtful that a commercial payer will accept a consultation code when Medicare has paid for a new or established patient service.

To add to the turmoil…

The CMS has announced that, as a result of the changes in Medicare policy on consultations, it is increasing the relative values for all new and established patient services and initial hospital care. CMS is doing this, however, by reducing the relative values of some consultation codes.

In addition, all surgical procedure codes that carry a 10- or 90-day global period will see an increase in work RVU because of the increase in E/M services that are a part of all global care. Keep in mind that payers who use the Resource-Based Relative Value Scale (RBRVS) to reimburse services will probably adopt the new values when contracts are up for renewal, although many will be unable to do so in the short term.

It also remains to be seen if any commercial payers adopt Medicare policy or continue to pay for consultations. This area might be a contract issue with payers.

Current Procedural Terminology (CPT) 2010, which took effect January 1, doesn’t bring many changes for ObGyn practice, but there’s been a major backpedaling in Medicare coverage of consultations that you must be aware of. In conjunction with this move by the Centers for Medicare & Medicaid Services (CMS), CPT has added a definition of “transfer of care” and established two possible reasons for providing a consultation. I’ll have more to report about these important developments later in this article.

Among the changes to billing codes for the work performed in ObGyn: rebundling of commonly performed urodynamics procedures and new codes for revision of a vaginal graft. There is also a new (and unpublished) code for administering the H1N1 influenza vaccine.

Last, CPT has revised the explanation of non–face-to-face prolonged services. Read on!

New codes bundle urodynamic studies—a product of joint CMS and CPT input

The biggest changes in coding for ObGyn procedures are urodynamics study codes. The American Medical Association (AMA) has 1) created three new codes that represent test bundles and, in the process, 2) deleted the stand-alone urodynamics codes 51772 (urethral pressure profile studies [UPP] [urethral closure pressure profile], any technique) and 51795 (voiding pressure studies; bladder voiding pressure, any technique).

These changes were made because the most commonly reported codes for a female patient were billed together 90% of the time (51726, 51772, 51795, and 51797); the AMA reasoned that the most frequent combinations were considered overvalued when billed separately—that is, there was no repeat of pre-test and post-test work when these combinations were performed and there was no duplication in the cost of supplies and staff time.

The new bundles were therefore considered to better reflect current medical practice, and the Relative Value Update Committee (RUC) recommended, and CMS accepted, the relative value units (RVU) for the combination codes to reflect the true physician work value and practice expense of the combined procedures.

New and revised codes are:

51726 Complex cystometrogram (i.e., calibrated electronic equipment)

51727 …with urethral pressure profile studies (i.e., urethral closure pressure profile), any technique

51728 …with voiding pressure studies (i.e., bladder voiding pressure), any technique

51729 …with voiding pressure studies (i.e., bladder voiding pressure) and urethral pressure profile studies (i.e., urethral closure pressure profile), any technique.

According to the clinical vignette submitted to the AMA for code 51727, this procedure will include a sustained Valsalva maneuver as part of the urethral closure pressure profile. CPT did, however, retain the add-on code +51797 (voiding pressure studies, intra-abdominal [i.e., rectal, gastric, intraperitoneal]) and has clarified that 51797 may be billed in addition to 51728 and 51729 if a rectal catheter is placed to determine if the patient is straining during the voiding event.

In other words, the add-on code may be reported only when the primary procedure includes a voiding pressure study.

RVU for these new procedures have also been revised (see the TABLE ). Notable is the seeming discrepancy in RVU between code 51726 (cystometrogram alone) and the bundled tests. This is the case because the practice expense for 51726 has not reached its final level (the practice expense RVU are being increased or decreased in increments over several years); for 2010 only, therefore, this code will have a higher total RVU value than the new codes (51727, 51728, 51729), despite having a lower physician work relative value.

The discrepancy will be corrected in 2011, when 51726 will have lower RVU than the other urodynamics combination test codes.

TABLE

Changes in 2010 to RVU for urodynamic studies

Laparoscopic revision of a vaginal graft

In 2006, the AMA added the code for a vaginal approach to revising a graft (57295, revision [including removal] of prosthetic vaginal graft; vaginal approach). Then, in 2007, it added a code for an abdominal approach (57296, revision [including removal] of prosthetic vaginal graft; open abdominal approach).

Now, you have a code for a laparoscopic approach, completing the code set for this procedure. As with 57295 and 57296, report the new code when the graft is either revised or removed entirely.

57426 Revision (including removal) of prosthetic vaginal graft, laparoscopic approach

Other, miscellaneous changes take effect

OBSTETRIC PANEL

Although code 80055 comprises a battery of tests that are performed routinely on obstetric patients, a new code, 86780, was created to report syphilis screening using a treponemal antibody method, in which IgM and IgG antibodies are measured. This test is not the same syphilis test that is now part of the 80055 panel. CPT has therefore cautioned that, when you use code 86780 instead of the standard syphilis test code 86592, you should not report the obstetrics panel but, instead, separately report each test performed.

REPRODUCTIVE MEDICINE

New code 89398 (unlisted reproductive medicine laboratory procedure) has been added, but CPT still directs billers to use the unlisted miscellaneous pathology test code 89240 to report cryopreservation of reproductive ovarian tissues.

BILLING FOR THE H1N1 INFLUENZA VACCINE

Because of the urgency of collecting data on the H1N1 influenza epidemic, CPT has revised code 90663 to include the H1N1 formulation of the flu vaccine product. In addition, CPT has created a new code, 90470, for administering the H1N1 flu vaccine, which became valid in September (but which isn’t included in the hard-copy version of CPT 2010). The new code is to be used for intramuscular injection or intranasal administration, and includes any time spent counseling.

In addition:

• Do not report established code 90471 (immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) when you administer the H1N1 flu vaccine
• Report the vaccine product code only when your practice has purchased the vaccine, or when the payer requires the code with a 0 charge to match the administration code.
• Medicare coding for administering the H1N1 flu vaccine is different than what I’ve just described. Do not use CPT codes for Medicare patients; instead, code H1N1 flu immunization as:

G9141 Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

G9142 Influenza A (H1N1) vaccine, any route of administration

Medicare will not reimburse for the vaccine product because it is being given to its providers without cost. Some carriers may require that the new vaccine product code be listed with a 0 charge.

Prolonged inpatient E/M services

CPT has revised guidelines for prolonged services that do not involve direct face-to-face contact with a patient. Keep in mind, however, that, although these changes are welcome, many payers don’t reimburse separately for work that isn’t performed face to face.

These codes are no longer considered add-on codes; they can be reported on a different date than the related E/M service.

According to CPT, codes 99358 and 99359 are reported when the prolonged time:

• is greater than would be expected for normal pre-service and post-service work associated with the E/M service
• exceeds 30 minutes
• is related to an E/M service that has already occurred, or to one that will occur and represents ongoing patient management (for example, your review of extensive patient records that weren’t available at the time of the visit)
• is in addition to any telephone services codes (99441–99443)—but not with more specific codes, such as medical team conferences, online medical evaluation, or care plan oversight services, which have no upper limit to the time required to accomplish the service.

Consultation codes and clarifications

Two changes of note, from a CPT perspective, have been made in the area of consultations. CPT has:

• added a definition for a transfer of care
• defined two circumstances under which a consultation can be coded. These revisions come at the same time Medicare has made the decision to no longer pay for consultations other than tele-health consults (see following section).

For 2010, CPT defines transfer of care as

…the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services.

The guidelines also explain that 1) a transferring physician is no longer responsible for caring for the problem for which the patient was referred and 2) the consultation codes should not be reported by the physician who accepts care.

Two alternative conditions must now apply for a consultation to be considered provided:

• A physician requested an opinion or advice for a specific condition or problem, or
• The consulting physician saw the patient first to determine whether to accept ongoing management of her entire care or of a specific condition or problem (i.e., transfer of care).

The second condition is new; it remains to be seen if payers will accept it as a valid reason to bill for consultation.

As with all billable services, you should ensure that the criteria required by the payer you are billing have been met. CPT also directs that the written request for consultation can be documented by either the requesting or the receiving physician—something that was unacceptable under Medicare guidelines.

Last, CPT has added instructions to clarify the type of consultation code to bill under certain circumstances:

• When the patient is admitted after an outpatient consultation but the physician does not see the patient on the unit on the date of admission, bill only for outpatient consultation
• When the patient is seen for an office visit, emergency room visit, or outpatient consult on the date of admission and the physician then sees the patient on the unit that day, bill only the inpatient consultation or initial hospital care code, whichever applies. All services that day are used to determine the final level of service.

Medicare tilts the playing field on consultations

Although CPT has retained all consultation codes, and although the hope is that commercial payers will continue to reimburse for such services in the near future, the big news is that Medicare has announced that it will no longer recognize (or reimburse for) codes for outpatient or inpatient consultations. (Note: This story is still unfolding, however. The changes announced by Medicare that I discuss below are still before Congress as this article goes to press. Although Medicare has, in fact, released the transmittal letter to all carriers instructing them about the changes, Senator Arlen Specter [D-Pa] has introduced an amendment to the Patient Protection and Affordable Care Act [H.R. 3590] to postpone the policy change for 1 year. If Congress has not passed this bill before the end of 2009, the changes go through as planned. Stay tuned for developments!)

Assuming the changes go through, here is what is expected of you in the circumstances of providing consultations and billing Medicare (Medicaid payers aren’t required to follow this policy change but may opt to do so).

Outpatients. Document, and report, the appropriate level of visit for a new or established Medicare patient using outpatient codes 99201–99215

Inpatients. If you are a non-admitting physician asked to see a patient for the first time, report the appropriate level of initial hospital care (codes 99221–99223). Note the following three points:

• Initial hospital care includes only three levels of service—not the five levels from which you choose for consultation codes
• The lowest level of history and exam for these initial visit codes is a detailed history and examination—no matter the level of medical decision-making. If the level of history or exam is documented lower than “detailed”—say, as “expanded problem-focused”—you are required to report the unlisted E/M code 99499.
• The admitting physician adds the new Healthcare Common Procedure Coding System (HCPCS) modifier –AI (that is, “‘A’ upper-case ‘i’”) to the initial visit code, so that Medicare can distinguish the admitting physician from others providing care for the patient.
• All subsequent visits with the inpatient continue to be billed with the subsequent care inpatient codes (99231–99233).

Fallout from this change? Medicare is studying the implications of its new policy on secondary payments—that is, when Medicare is the primary payer and there is a supplemental carrier, or when Medicare is the secondary payer. Note: Medicare strongly advises all providers to check with their primary payers, because 1) Medicare will not accept a consultation code when a primary insurer has paid on that code and 2) it’s doubtful that a commercial payer will accept a consultation code when Medicare has paid for a new or established patient service.

To add to the turmoil…

The CMS has announced that, as a result of the changes in Medicare policy on consultations, it is increasing the relative values for all new and established patient services and initial hospital care. CMS is doing this, however, by reducing the relative values of some consultation codes.

In addition, all surgical procedure codes that carry a 10- or 90-day global period will see an increase in work RVU because of the increase in E/M services that are a part of all global care. Keep in mind that payers who use the Resource-Based Relative Value Scale (RBRVS) to reimburse services will probably adopt the new values when contracts are up for renewal, although many will be unable to do so in the short term.

It also remains to be seen if any commercial payers adopt Medicare policy or continue to pay for consultations. This area might be a contract issue with payers.

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

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

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

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

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

Changes to obstetric codes

PUERPERAL INFECTIONS

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

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

670.1x [0,2,4]  Puerperal endometritis

670.2x [0,2,4]  Puerperal sepsis

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

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

VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM

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

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

Gyn code changes

HYPERPLASIA

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

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

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

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

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

621.34  Benign endometrial hyperplasia

621.35  Endometrial intraepithelial neoplasia

INCONCLUSIVE MAMMOGRAM

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

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

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

793.82  Inconclusive mammogram

FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY

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

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

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

V26.42  Encounter for fertility preservation counseling

V26.82  Encounter for fertility preservation procedure

PREPROCEDURAL EVALUATIONS

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

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

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

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

V72.60  Laboratory examination, unspecified

V72.61  Antibody response examination

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

V72.63  Preprocedural laboratory examination

V72.69  Other laboratory examination

PERSONAL HISTORY CODES

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

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

V87.43  Personal history of estrogen therapy

V87.44  Personal history of inhaled steroid therapy

V87.45  Personal history of systemic steroid therapy

V87.46  Personal history of immunosuppressive therapy

Plus a number of miscellaneous additions and changes

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

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

995.24  Failed moderate sedation during procedure

V10.90  Personal history of unspecified type of malignant neoplasm

V15.80  Personal history of failed moderate sedation

V61.07  Family disruption due to death of family member

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

V61.42  Substance abuse in family

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

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

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

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

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

Changes to obstetric codes

PUERPERAL INFECTIONS

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

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

670.1x [0,2,4]  Puerperal endometritis

670.2x [0,2,4]  Puerperal sepsis

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

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

VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM

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

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

Gyn code changes

HYPERPLASIA

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

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

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

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

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

621.34  Benign endometrial hyperplasia

621.35  Endometrial intraepithelial neoplasia

INCONCLUSIVE MAMMOGRAM

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

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

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

793.82  Inconclusive mammogram

FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY

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

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

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

V26.42  Encounter for fertility preservation counseling

V26.82  Encounter for fertility preservation procedure

PREPROCEDURAL EVALUATIONS

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

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

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

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

V72.60  Laboratory examination, unspecified

V72.61  Antibody response examination

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

V72.63  Preprocedural laboratory examination

V72.69  Other laboratory examination

PERSONAL HISTORY CODES

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

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

V87.43  Personal history of estrogen therapy

V87.44  Personal history of inhaled steroid therapy

V87.45  Personal history of systemic steroid therapy

V87.46  Personal history of immunosuppressive therapy

Plus a number of miscellaneous additions and changes

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

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

995.24  Failed moderate sedation during procedure

V10.90  Personal history of unspecified type of malignant neoplasm

V15.80  Personal history of failed moderate sedation

V61.07  Family disruption due to death of family member

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

V61.42  Substance abuse in family

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

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

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

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

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

Changes to obstetric codes

PUERPERAL INFECTIONS

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

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

670.1x [0,2,4]  Puerperal endometritis

670.2x [0,2,4]  Puerperal sepsis

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

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

VENOUS COMPLICATIONS IN PREGNANCY AND PUERPERIUM

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

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

Gyn code changes

HYPERPLASIA

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

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

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

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

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

621.34  Benign endometrial hyperplasia

621.35  Endometrial intraepithelial neoplasia

INCONCLUSIVE MAMMOGRAM

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

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

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

793.82  Inconclusive mammogram

FERTILITY PRESERVATION PRIOR TO ANTINEOPLASTIC THERAPY

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

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

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

V26.42  Encounter for fertility preservation counseling

V26.82  Encounter for fertility preservation procedure

PREPROCEDURAL EVALUATIONS

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

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

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

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

V72.60  Laboratory examination, unspecified

V72.61  Antibody response examination

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

V72.63  Preprocedural laboratory examination

V72.69  Other laboratory examination

PERSONAL HISTORY CODES

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

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

V87.43  Personal history of estrogen therapy

V87.44  Personal history of inhaled steroid therapy

V87.45  Personal history of systemic steroid therapy

V87.46  Personal history of immunosuppressive therapy

Plus a number of miscellaneous additions and changes

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

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

995.24  Failed moderate sedation during procedure

V10.90  Personal history of unspecified type of malignant neoplasm

V15.80  Personal history of failed moderate sedation

V61.07  Family disruption due to death of family member

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

V61.42  Substance abuse in family

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

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

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

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

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

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

When you provide counseling, bill for it!

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

Include the proper diagnostic code

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

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

Just what constitutes “routine” testing?

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

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

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

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

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

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

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

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

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

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

When you provide counseling, bill for it!

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

Include the proper diagnostic code

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

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

Just what constitutes “routine” testing?

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

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

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

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

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

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

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

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

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

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

When you provide counseling, bill for it!

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

Include the proper diagnostic code

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

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

Just what constitutes “routine” testing?

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

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

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

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