Melanie Witt, RN, CPC-OGS, MA

PROM and global OB care: Billing is all about timing

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

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

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

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

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

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

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

PROM and global OB care: Billing is all about timing

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

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

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

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

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

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

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

PROM and global OB care: Billing is all about timing

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

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

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

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

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

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

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

Pinpoint pelvic pain to avoid denial for US scan

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

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

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

Problem with -52 modifier for US follicle evaluation

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

Can you comment on our coding strategies for these services?

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

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

Dx/procedure mismatch when checking for fibroids

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

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

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

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

Pinpoint pelvic pain to avoid denial for US scan

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

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

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

Problem with -52 modifier for US follicle evaluation

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

Can you comment on our coding strategies for these services?

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

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

Dx/procedure mismatch when checking for fibroids

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

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

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

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

Pinpoint pelvic pain to avoid denial for US scan

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

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

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

Problem with -52 modifier for US follicle evaluation

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

Can you comment on our coding strategies for these services?

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

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

Dx/procedure mismatch when checking for fibroids

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

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

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

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

Rewards await in 2008 for meeting quality measures

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

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

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

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

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

The list doesn’t stop there: New measures cover the use of electronic medical records, e-prescribing, and advising a patient to get the flu vaccine. And so on.

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

Reimbursement for repair of your surgical injury?

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

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

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

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

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

Rewards await in 2008 for meeting quality measures

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

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

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

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

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

The list doesn’t stop there: New measures cover the use of electronic medical records, e-prescribing, and advising a patient to get the flu vaccine. And so on.

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

Reimbursement for repair of your surgical injury?

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

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

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

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

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

Rewards await in 2008 for meeting quality measures

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

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

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

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

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

The list doesn’t stop there: New measures cover the use of electronic medical records, e-prescribing, and advising a patient to get the flu vaccine. And so on.

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

Reimbursement for repair of your surgical injury?

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

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

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

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

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

Making “non–face-to-face” contact with a patient

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

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

Patient-initiated telephone contact

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

99442  …11–20 minutes of medical discussion

99443  …21–30 minutes of medical discussion

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

98967  …11–20 minutes of medical discussion

98968  …21–30 minutes of medical discussion

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

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

Conferring with the medical team

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

99368  …participation by nonphysician qualified health care professional

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

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

Providing your services online

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

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

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

Criteria for using these new codes are:

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

Making “non–face-to-face” contact with a patient

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

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

Patient-initiated telephone contact

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

99442  …11–20 minutes of medical discussion

99443  …21–30 minutes of medical discussion

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

98967  …11–20 minutes of medical discussion

98968  …21–30 minutes of medical discussion

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

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

Conferring with the medical team

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

99368  …participation by nonphysician qualified health care professional

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

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

Providing your services online

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

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

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

Criteria for using these new codes are:

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

Making “non–face-to-face” contact with a patient

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

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

Patient-initiated telephone contact

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

99442  …11–20 minutes of medical discussion

99443  …21–30 minutes of medical discussion

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

98967  …11–20 minutes of medical discussion

98968  …21–30 minutes of medical discussion

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

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

Conferring with the medical team

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

99368  …participation by nonphysician qualified health care professional

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

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

Providing your services online

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

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

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

Criteria for using these new codes are:

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

In 2008, long-awaited surgical codes are being added to Current Procedural Terminology (CPT) for total laparoscopic hysterectomy and repair of a paravaginal defect. Pay attention to code renumbering and revisions in the New Year, too: Bladder aspiration codes have new numbers, and removal of an intra-abdominal tumor will require more careful documentation, to cite two changes.

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

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

Specify repair of paravaginal defect

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

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

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

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

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

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

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

Total lap hysterectomy

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

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

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

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

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

Intraperitoneal tumors, coded by size

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

49204 …largest tumor 5.1–10.0 cm diameter

49205 …largest tumor greater than 10.0 cm diameter

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

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

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

Bladder aspiration is renumbered

51100 Aspiration of bladder; by needle

 

51101 …by trocar or intracatheter

51102 …with insertion of suprapubic catheter

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

Giving flu, HPV vaccines

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

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

90663 Influenza virus vaccine, pandemic formulation

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

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

Changes made to “modifier -51” exemptions

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

In 2008, long-awaited surgical codes are being added to Current Procedural Terminology (CPT) for total laparoscopic hysterectomy and repair of a paravaginal defect. Pay attention to code renumbering and revisions in the New Year, too: Bladder aspiration codes have new numbers, and removal of an intra-abdominal tumor will require more careful documentation, to cite two changes.

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

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

Specify repair of paravaginal defect

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

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

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

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

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

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

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

Total lap hysterectomy

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

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

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

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

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

Intraperitoneal tumors, coded by size

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

49204 …largest tumor 5.1–10.0 cm diameter

49205 …largest tumor greater than 10.0 cm diameter

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

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

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

Bladder aspiration is renumbered

51100 Aspiration of bladder; by needle

 

51101 …by trocar or intracatheter

51102 …with insertion of suprapubic catheter

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

Giving flu, HPV vaccines

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

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

90663 Influenza virus vaccine, pandemic formulation

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

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

Changes made to “modifier -51” exemptions

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

In 2008, long-awaited surgical codes are being added to Current Procedural Terminology (CPT) for total laparoscopic hysterectomy and repair of a paravaginal defect. Pay attention to code renumbering and revisions in the New Year, too: Bladder aspiration codes have new numbers, and removal of an intra-abdominal tumor will require more careful documentation, to cite two changes.

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

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

Specify repair of paravaginal defect

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

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

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

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

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

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

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

Total lap hysterectomy

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

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

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

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

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

Intraperitoneal tumors, coded by size

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

49204 …largest tumor 5.1–10.0 cm diameter

49205 …largest tumor greater than 10.0 cm diameter

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

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

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

Bladder aspiration is renumbered

51100 Aspiration of bladder; by needle

 

51101 …by trocar or intracatheter

51102 …with insertion of suprapubic catheter

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

Giving flu, HPV vaccines

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

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

90663 Influenza virus vaccine, pandemic formulation

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

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

Changes made to “modifier -51” exemptions

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

Can US scan be used to confirm a normal pelvic exam?

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

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

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

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

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

Slow payment for unlisted codes for lap hysterectomy

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

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

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

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

No need for modifiers on self-performed US scans

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

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

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

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

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

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

 

Colporrhaphy? Do not code for posterior repair

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

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

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

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

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

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

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

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

Can US scan be used to confirm a normal pelvic exam?

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

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

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

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

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

Slow payment for unlisted codes for lap hysterectomy

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

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

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

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

No need for modifiers on self-performed US scans

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

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

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

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

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

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

 

Colporrhaphy? Do not code for posterior repair

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

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

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

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

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

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

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

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

Can US scan be used to confirm a normal pelvic exam?

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

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

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

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

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

Slow payment for unlisted codes for lap hysterectomy

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

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

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

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

No need for modifiers on self-performed US scans

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

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

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

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

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

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

 

Colporrhaphy? Do not code for posterior repair

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

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

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

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

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

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

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

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

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

Vaginal, vulvar conditions: Simpler reporting

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

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

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

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

New code for trauma during delivery

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

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

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

Report dysplasia follow-up as “medical necessity”

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

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

Better documentation of malignant ascites

789.51  Malignant ascites

789.59  Other ascites

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

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

 

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

Assisted reproductive fertility procedure status

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

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

Natural family planning comes of age

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

V26.41  Procreative counseling and advice using natural family planning

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

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

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

V26.49  Other procreative management counseling and advice

Disability certificates, made easy(ier) to report

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

V68.01  Disability examination

V68.09  Other issue of medical certificates

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

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

Diversified codes for iatrogenic ID complications

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

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

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

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

Vaginal, vulvar conditions: Simpler reporting

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

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

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

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

New code for trauma during delivery

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

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

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

Report dysplasia follow-up as “medical necessity”

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

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

Better documentation of malignant ascites

789.51  Malignant ascites

789.59  Other ascites

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

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

 

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

Assisted reproductive fertility procedure status

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

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

Natural family planning comes of age

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

V26.41  Procreative counseling and advice using natural family planning

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

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

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

V26.49  Other procreative management counseling and advice

Disability certificates, made easy(ier) to report

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

V68.01  Disability examination

V68.09  Other issue of medical certificates

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

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

Diversified codes for iatrogenic ID complications

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

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

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

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

Vaginal, vulvar conditions: Simpler reporting

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

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

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

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

New code for trauma during delivery

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

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

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

Report dysplasia follow-up as “medical necessity”

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

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

Better documentation of malignant ascites

789.51  Malignant ascites

789.59  Other ascites

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

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

 

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

Assisted reproductive fertility procedure status

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

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

Natural family planning comes of age

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

V26.41  Procreative counseling and advice using natural family planning

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

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

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

V26.49  Other procreative management counseling and advice

Disability certificates, made easy(ier) to report

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

V68.01  Disability examination

V68.09  Other issue of medical certificates

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

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

Diversified codes for iatrogenic ID complications

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

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

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

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

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

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

How do I report an intervention?

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

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

The measure specifications are organized to provide specific information:

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

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

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

TABLE

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

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

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

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

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

How do I report an intervention?

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

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

The measure specifications are organized to provide specific information:

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

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

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

TABLE

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

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

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

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

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

How do I report an intervention?

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

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

The measure specifications are organized to provide specific information:

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

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

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

TABLE

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

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

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

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

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

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

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

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

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

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

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

Payer may balk at modified biophysical profile

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

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

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

Hysteroscopy before but not during thermoablation

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

Payer may balk at modified biophysical profile

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

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

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

Hysteroscopy before but not during thermoablation

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

Payer may balk at modified biophysical profile

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

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

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

Hysteroscopy before but not during thermoablation

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

 

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

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

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

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

Be consistent with the fifth digit across delivery codes!

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

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

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

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

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

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

Bundle codes for repair of a pelvic floor defect?

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

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

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

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

Be consistent with the fifth digit across delivery codes!

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

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

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

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

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

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

Bundle codes for repair of a pelvic floor defect?

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

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

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

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

Be consistent with the fifth digit across delivery codes!

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

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

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

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

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

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

Bundle codes for repair of a pelvic floor defect?

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

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

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

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