Melanie Witt, RN, CPC-OGS, MA

Q During a sling procedure for stress urinary incontinence, the surgeon accidentally knicked the bladder, which was then repaired, and a cystoscopy was also performed. These procedures were denied as included in the sling procedure. This was a Medicare patient.

A Unfortunately, your coding ran afoul of established National Correct Coding Initiative (NCCI) bundling and general guidelines.

I assume that you appropriately used the ICD-9-CM code 998.2 (Accidental puncture or laceration during a procedure) when billing for the suture of the bladder (51860, Cystorrhaphy, suture of bladder wound, injury or rupture; simple or 51865,.......; complicated).

Although neither of these codes is bundled with the sling procedure (57288, Sling operation for stress incontinence [eg, fascia or synthetic]), the general rules for NCCI state: “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.” The use of the complication diagnosis would trigger the denial.

In addition, you apparently billed code 52000 (Cystourethroscopy [separate procedure]), and this code is bundled into code 57288 with a “0” indicator, which means that the edit cannot be bypassed using any modifier.

The good news

These rules would only apply to Medicare or to payers who use Medicare rules. Although you may find that 52000 may be a common bundle by many payers, you will not usually find commercial insurance denying the repair of the complication during surgery.

Q During a sling procedure for stress urinary incontinence, the surgeon accidentally knicked the bladder, which was then repaired, and a cystoscopy was also performed. These procedures were denied as included in the sling procedure. This was a Medicare patient.

A Unfortunately, your coding ran afoul of established National Correct Coding Initiative (NCCI) bundling and general guidelines.

I assume that you appropriately used the ICD-9-CM code 998.2 (Accidental puncture or laceration during a procedure) when billing for the suture of the bladder (51860, Cystorrhaphy, suture of bladder wound, injury or rupture; simple or 51865,.......; complicated).

Although neither of these codes is bundled with the sling procedure (57288, Sling operation for stress incontinence [eg, fascia or synthetic]), the general rules for NCCI state: “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.” The use of the complication diagnosis would trigger the denial.

In addition, you apparently billed code 52000 (Cystourethroscopy [separate procedure]), and this code is bundled into code 57288 with a “0” indicator, which means that the edit cannot be bypassed using any modifier.

The good news

These rules would only apply to Medicare or to payers who use Medicare rules. Although you may find that 52000 may be a common bundle by many payers, you will not usually find commercial insurance denying the repair of the complication during surgery.

Q During a sling procedure for stress urinary incontinence, the surgeon accidentally knicked the bladder, which was then repaired, and a cystoscopy was also performed. These procedures were denied as included in the sling procedure. This was a Medicare patient.

A Unfortunately, your coding ran afoul of established National Correct Coding Initiative (NCCI) bundling and general guidelines.

I assume that you appropriately used the ICD-9-CM code 998.2 (Accidental puncture or laceration during a procedure) when billing for the suture of the bladder (51860, Cystorrhaphy, suture of bladder wound, injury or rupture; simple or 51865,.......; complicated).

Although neither of these codes is bundled with the sling procedure (57288, Sling operation for stress incontinence [eg, fascia or synthetic]), the general rules for NCCI state: “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.” The use of the complication diagnosis would trigger the denial.

In addition, you apparently billed code 52000 (Cystourethroscopy [separate procedure]), and this code is bundled into code 57288 with a “0” indicator, which means that the edit cannot be bypassed using any modifier.

The good news

These rules would only apply to Medicare or to payers who use Medicare rules. Although you may find that 52000 may be a common bundle by many payers, you will not usually find commercial insurance denying the repair of the complication during surgery.

Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Q I performed a resection of a submucous fibroid and also did uterine curettage. I will report code 58561 (Hysteroscopy, surgical; with removal of leiomyomata) for the primary procedure, but can I also bill for the curettage?

A Yes. Code 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) is not bundled with code 58561 under the National Correct Coding Initiative (NCCI). But to avoid denial you must establish medical justification for doing the curettage by indicating a diagnosis other than submucous fibroid (218.0).

Q I performed a resection of a submucous fibroid and also did uterine curettage. I will report code 58561 (Hysteroscopy, surgical; with removal of leiomyomata) for the primary procedure, but can I also bill for the curettage?

A Yes. Code 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) is not bundled with code 58561 under the National Correct Coding Initiative (NCCI). But to avoid denial you must establish medical justification for doing the curettage by indicating a diagnosis other than submucous fibroid (218.0).

Q I performed a resection of a submucous fibroid and also did uterine curettage. I will report code 58561 (Hysteroscopy, surgical; with removal of leiomyomata) for the primary procedure, but can I also bill for the curettage?

A Yes. Code 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) is not bundled with code 58561 under the National Correct Coding Initiative (NCCI). But to avoid denial you must establish medical justification for doing the curettage by indicating a diagnosis other than submucous fibroid (218.0).

Q How do you code a positive test for human papillomavirus high-risk DNA (795.05) in a pregnant patient?

A The most accurate code for this finding would be 647.63 (Other viral diseases). This code includes conditions classifiable to HPV. Your secondary diagnosis will be 795.05.

Q How do you code a positive test for human papillomavirus high-risk DNA (795.05) in a pregnant patient?

A The most accurate code for this finding would be 647.63 (Other viral diseases). This code includes conditions classifiable to HPV. Your secondary diagnosis will be 795.05.

Q How do you code a positive test for human papillomavirus high-risk DNA (795.05) in a pregnant patient?

A The most accurate code for this finding would be 647.63 (Other viral diseases). This code includes conditions classifiable to HPV. Your secondary diagnosis will be 795.05.

Q We perform diagnostic and operative hysteroscopy in our office. How do we recoup our loss compared with the hospital? Can we bill a separate physician and technical component?

A The Medicare Resource-Based Relative Value Scale (RBRVS) normally allows a practice expense increase for procedures that may be performed in the office and require expensive equipment, but are more typically performed in the hospital. The Medicare Relative Value Unit (RVU) is 9.42 for code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). For hysteroscopy procedures, there is no difference in the RVU for site of service—with 3 exceptions:

• Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
  
• Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
  
• Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
  

The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.

Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.

Q We perform diagnostic and operative hysteroscopy in our office. How do we recoup our loss compared with the hospital? Can we bill a separate physician and technical component?

A The Medicare Resource-Based Relative Value Scale (RBRVS) normally allows a practice expense increase for procedures that may be performed in the office and require expensive equipment, but are more typically performed in the hospital. The Medicare Relative Value Unit (RVU) is 9.42 for code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). For hysteroscopy procedures, there is no difference in the RVU for site of service—with 3 exceptions:

• Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
  
• Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
  
• Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
  

The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.

Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.

Q We perform diagnostic and operative hysteroscopy in our office. How do we recoup our loss compared with the hospital? Can we bill a separate physician and technical component?

A The Medicare Resource-Based Relative Value Scale (RBRVS) normally allows a practice expense increase for procedures that may be performed in the office and require expensive equipment, but are more typically performed in the hospital. The Medicare Relative Value Unit (RVU) is 9.42 for code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). For hysteroscopy procedures, there is no difference in the RVU for site of service—with 3 exceptions:

• Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
  
• Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
  
• Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
  

The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.

Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q My patient who was 7 months pregnant presented to the ER with abdominal pain. She was sent to labor and delivery, where I treated and discharged her. Should I use the observation codes for this or just an outpatient visit code?

A You need to determine whether you admitted the patient to observation status (which is not the same thing as admission to the hospital) or saw the patient, treated her, and then sent her home.

Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.

The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).

If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q My patient who was 7 months pregnant presented to the ER with abdominal pain. She was sent to labor and delivery, where I treated and discharged her. Should I use the observation codes for this or just an outpatient visit code?

A You need to determine whether you admitted the patient to observation status (which is not the same thing as admission to the hospital) or saw the patient, treated her, and then sent her home.

Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.

The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).

If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q My patient who was 7 months pregnant presented to the ER with abdominal pain. She was sent to labor and delivery, where I treated and discharged her. Should I use the observation codes for this or just an outpatient visit code?

A You need to determine whether you admitted the patient to observation status (which is not the same thing as admission to the hospital) or saw the patient, treated her, and then sent her home.

Timing is everything. Although the codes for observation care do not stipulate a time period, the record must clearly show that she was observed before a determination could be made to send her home or admit her to the hospital. This would include being seen first by you and then having nursing staff observe for problems prior to your deciding to send her home.

The observation codes require, at a minimum, documentation of a detailed history and exam (with any level of medical decision making). If your patient was admitted and discharged on the same service date, the codes you would select from are 99234-99236 (observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date).

If, on the other hand, you saw the patient, treated her, and then immediately released her to go home or you left orders to send her home after a test had been performed such as a nonstress test, you should consider this to be an outpatient service and you would report one of the established patient problem codes (99212-99215).

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What diagnosis should be reported for an induced delivery at 30 weeks for preeclampsia?

A The answer depends on whether you induced labor for delivery or went immediately to a cesarean delivery.

In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.

If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).

If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What diagnosis should be reported for an induced delivery at 30 weeks for preeclampsia?

A The answer depends on whether you induced labor for delivery or went immediately to a cesarean delivery.

In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.

If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).

If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What diagnosis should be reported for an induced delivery at 30 weeks for preeclampsia?

A The answer depends on whether you induced labor for delivery or went immediately to a cesarean delivery.

In either case, report the ICD-9-CM code that supports the type of preeclampsia (eg, 642.51, severe preeclampsia; delivered with or without mention of antepartum condition). But if labor was induced, add code 644.21 (early onset of delivery; delivered with or without mention of antepartum condition). This code represents premature labor with delivery before 37 completed weeks of gestation.

If the delivery was accomplished by performing a cesarean, in addition to an outcome code such as V27.0 (single liveborn), you might add a code if the patient had a previous cesarean delivery (654.21).

If this was her first cesarean delivery, only the preeclampsia and outcome diagnosis codes would be assigned.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient has a sonogram to check for fetal heart tones and only a gestational sac (g-sac) with no fetal pole is found, is the sonogram coded as a limited OB or a GYN ultrasound, because the patient is not pregnant? Also, for a diagnosis of g-sac with no fetal pole, is it correct to code a blighted ovum (usually these patients are less than 10 weeks pregnant)?

A Technically, when a gestational sac is present, the patient is still pregnant, so the GYN codes are inappropriate. And yes, you should assign the diagnostic code for blighted ovum (ICD-9-CM code 631).

If the purpose of the ultrasound is only to check for fetal heart tones, then the correct code is 76815 (ultrasound, pregnant uterus, real time with image documentation limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses).

While this scan could be performed transvaginally, the amount of work in checking only for fetal heart tones is significantly less than that involved in the OB transvaginal procedure.

Therefore, I recommend that you use the limited ultrasound code even if a vaginal probe was used.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient has a sonogram to check for fetal heart tones and only a gestational sac (g-sac) with no fetal pole is found, is the sonogram coded as a limited OB or a GYN ultrasound, because the patient is not pregnant? Also, for a diagnosis of g-sac with no fetal pole, is it correct to code a blighted ovum (usually these patients are less than 10 weeks pregnant)?

A Technically, when a gestational sac is present, the patient is still pregnant, so the GYN codes are inappropriate. And yes, you should assign the diagnostic code for blighted ovum (ICD-9-CM code 631).

If the purpose of the ultrasound is only to check for fetal heart tones, then the correct code is 76815 (ultrasound, pregnant uterus, real time with image documentation limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses).

While this scan could be performed transvaginally, the amount of work in checking only for fetal heart tones is significantly less than that involved in the OB transvaginal procedure.

Therefore, I recommend that you use the limited ultrasound code even if a vaginal probe was used.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When a patient has a sonogram to check for fetal heart tones and only a gestational sac (g-sac) with no fetal pole is found, is the sonogram coded as a limited OB or a GYN ultrasound, because the patient is not pregnant? Also, for a diagnosis of g-sac with no fetal pole, is it correct to code a blighted ovum (usually these patients are less than 10 weeks pregnant)?

A Technically, when a gestational sac is present, the patient is still pregnant, so the GYN codes are inappropriate. And yes, you should assign the diagnostic code for blighted ovum (ICD-9-CM code 631).

If the purpose of the ultrasound is only to check for fetal heart tones, then the correct code is 76815 (ultrasound, pregnant uterus, real time with image documentation limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses).

While this scan could be performed transvaginally, the amount of work in checking only for fetal heart tones is significantly less than that involved in the OB transvaginal procedure.

Therefore, I recommend that you use the limited ultrasound code even if a vaginal probe was used.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When we start giving the new HPV vaccine, how do we bill for it?

A On June 8, 2006, the Food and Drug Administration (FDA) officially licensed the HPV vaccine for use in girls and women ages 9 to 26.

• 90649 is the vaccine product code (human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use). A 3-dose schedule means you will be billing for the procedure 3 times during a 6-month period.
  
• 90471 can also be reported for the administration of the vaccine. (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid])
  

Adding modifiers. CPT guidelines state that a modifier -51 (multiple procedure) would not be added to either of these codes, and of course if you provide a significant and separate evaluation and management (E/M) service at the time the vaccine is given, you may also bill an E/M code with a modifier -25 added to let the payer know that the E/M service was separate.

Note that almost no payers will pay separately for the E/M code 99211 plus an injection procedure because it represents a minimal, not a significant E/M service.

Insurance coverage unlikely, for now

Until such time as the CDC comes out with a recommendation for the vaccine, coverage is going to be a problem. Insurance plans can be expected to cover the cost of the vaccine only if the CDC Advisory Committee on Immunization Practices recommends HPV vaccination as standard.

Tell patients! Until then, you may want to advise your patients who are candidates for the vaccine that this vaccine may be an out-of-pocket expense for them. Merck, the company that produces the quadrivalent vaccine, has stated that the price will be $120 per injection. The company has indicated that they have created a new program to provide free vaccines including HPV vaccine, for uninsured adults unable to pay.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When we start giving the new HPV vaccine, how do we bill for it?

A On June 8, 2006, the Food and Drug Administration (FDA) officially licensed the HPV vaccine for use in girls and women ages 9 to 26.

• 90649 is the vaccine product code (human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use). A 3-dose schedule means you will be billing for the procedure 3 times during a 6-month period.
  
• 90471 can also be reported for the administration of the vaccine. (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid])
  

Adding modifiers. CPT guidelines state that a modifier -51 (multiple procedure) would not be added to either of these codes, and of course if you provide a significant and separate evaluation and management (E/M) service at the time the vaccine is given, you may also bill an E/M code with a modifier -25 added to let the payer know that the E/M service was separate.

Note that almost no payers will pay separately for the E/M code 99211 plus an injection procedure because it represents a minimal, not a significant E/M service.

Insurance coverage unlikely, for now

Until such time as the CDC comes out with a recommendation for the vaccine, coverage is going to be a problem. Insurance plans can be expected to cover the cost of the vaccine only if the CDC Advisory Committee on Immunization Practices recommends HPV vaccination as standard.

Tell patients! Until then, you may want to advise your patients who are candidates for the vaccine that this vaccine may be an out-of-pocket expense for them. Merck, the company that produces the quadrivalent vaccine, has stated that the price will be $120 per injection. The company has indicated that they have created a new program to provide free vaccines including HPV vaccine, for uninsured adults unable to pay.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q When we start giving the new HPV vaccine, how do we bill for it?

A On June 8, 2006, the Food and Drug Administration (FDA) officially licensed the HPV vaccine for use in girls and women ages 9 to 26.

• 90649 is the vaccine product code (human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use). A 3-dose schedule means you will be billing for the procedure 3 times during a 6-month period.
  
• 90471 can also be reported for the administration of the vaccine. (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid])
  

Adding modifiers. CPT guidelines state that a modifier -51 (multiple procedure) would not be added to either of these codes, and of course if you provide a significant and separate evaluation and management (E/M) service at the time the vaccine is given, you may also bill an E/M code with a modifier -25 added to let the payer know that the E/M service was separate.

Note that almost no payers will pay separately for the E/M code 99211 plus an injection procedure because it represents a minimal, not a significant E/M service.

Insurance coverage unlikely, for now

Until such time as the CDC comes out with a recommendation for the vaccine, coverage is going to be a problem. Insurance plans can be expected to cover the cost of the vaccine only if the CDC Advisory Committee on Immunization Practices recommends HPV vaccination as standard.

Tell patients! Until then, you may want to advise your patients who are candidates for the vaccine that this vaccine may be an out-of-pocket expense for them. Merck, the company that produces the quadrivalent vaccine, has stated that the price will be $120 per injection. The company has indicated that they have created a new program to provide free vaccines including HPV vaccine, for uninsured adults unable to pay.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.