pregnancy coding scenarios

346.90 Migraine, w/o mention of intractable or status migrainosus, O14.Ø3 Mild to moderate preeclampsia, third trimester Obstetrical care is defined as global for six weeks past the delivery date. 76802-each additional gestation (List separately in addition to code for primary procedure) 76805– Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation For example, the physician’s documentation might specify: “There were dense adhesions from the bladder to the uterus appearing to have grown to the patient’s uterus from a prior cesarean. Earn CEUs and the respect of your peers. Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC, and Susan Proctor, RHIT, CCS, CPC, review the relevant coding guidelines for coders who handle coding for these patient encounters. ICD-10-CM can now capture the side of the body. No specific impact noted. 27 Coding Scenario #2 The pati ttient is a 28 year old flfemale with a positive Cystometrogram measures how well the bladder stores and empties urine; for instance, for patients with symptoms of urinary incompetence. Last Pap was normal. As per ICD 10 coding, incidental pregnancy is a test that proves that the patient is pregnant. Referred for concern of delayed gross motor skills. – 88155 in addition to the screening code for physician interpretation of a cervical or vaginal specimen that has been screened by any method using any system of reporting • add-on code reported in addition to code for the technical service provided. Current guidelines indicate that ICD-9-CM code 648.21 is the principal diagnosis for a woman with a pregnancy complicated by anemia who undergoes a cesarean delivery due to fetal distress not present at admission, says Susan Proctor, RHIT, CCS, CPC, a coding consultant in Willits, Calif., and an AHIMA-certified ICD-10-CM/PCS trainer. “I’ve found a lump on my left breast and I need my annual GYN exam.”. V84.01 Genetic susceptibility, malignant neoplasm breast, N63 Unspecified lump in breast, which includes: nodule(s) NOS in breast For diagnosis coding, use ICD-10-CM code range of O00-O9A with sequencing priority over codes from other categories. Pregnant state, incidental. Over the past 2 days she has not been able to perform usual activities due to her symptoms. Capturing the appropriate side of the body is important, as some payers may deny claims without this information. Bed rest was ordered until delivery. Left breast examined normal except for 1.5cm mass on left lower/outer quadrant5. During pregnancy, childbirth or the puerperium, when COVID-19 is the reason for admission/encounter, code O98.5 -, Other viral diseases complicating pregnancy, childbirth and the puerperium, should be sequenced as the principal/first-listed diagnosis, and code U07.1, COVID-19, and the appropriate codes for associated manifestation (s) should be assigned as additional diagnoses. Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually. Coding and billing professionals must keep track of reporting requirements for visit services administered remotely using telemedicine and updates to the ICD-10-CM guidelines for reporting COVID-19 in pregnancy. As a contributor you will produce quality content for the business of healthcare, taking the Knowledge Center forward with your knowhow and expertise. Begin Megacode 3 . Code the following scenario according to ICD-10 coding conventions and guidelines: Due to ailing health, Jane?s grandfather will be moving in with her in a few months. Be aware of surgical guidelines when contracting with private payers. 47 year old perimenopausal female. Inside, there are key data points and specific guidelines that must be followed at all times. V72.31 Routine gynecologic exam, with or without pap test Most role plays will last only a minute or two. V13.29 Personal history of other genital system and obstetric disorders, N94.89 OR Other specified conditions associated with female genital organs and menstrual cycle CDSA SCENARIOS. From those graphs or images, a provider interprets the patient’s condition and makes recommendations about treatment, therapy, or surgery that is translated into a written report. Discussed and administered HPV vaccine in office today. Pain Rx also given. – 88155 in addition to the screening code for physician interpretation of a cervical or vaginal specimen that has been screened by any method using any system of reporting • add-on code reported in addition to code for the technical service provided. Historically cycles have been regular lasting 28 – 30 days each. No previous mammograms. 51729 with bladder voiding pressure studies, urethral pressure studies, any technique LMP was 4 months ago. To qualify for Medicare coverage, a screening pelvic exam must include at least seven of the following 11 elements: Pelvic examination (with or without specimen collection for smears and cultures) including: Reporting and reimbursement for BPP services requires specific HCPCS Level II and ICD-9-CM codes. Eclampsia is when seizures are associated with the preeclampsia condition. Did the adhesions distort the anatomy? Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings To clarify, bacterial vaginosis is not considered an STI and physician recommendations for abstaining from sexual activity varies from physician to physician. 6 . Should I use E11.69 or E11.29? |  EHR Certification |  EHR Status. Patient reports eating 12 sausages at the Sunday church breakfast five days ago which he believes initiated his symptoms. The services you’ll include, or bundle into, the global surgical package will depend on the payer for a particular claim. V04.89 Need for prophylactic vaccination and inoculation against other viral diseases, Index to Diseases for ICD-9-CM under the word itching states “see also Pruritis”. 626.4 Irregular menstrual cycle No palpable ovarian or uterine enlargement. In this case, appending modifier 22 to the primary procedure code is justified, along with a request for additional payment based on the unusually difficult or time-consuming nature of the procedure. R10.813 Right lower quadrant abdominal tenderness 629.89 OR Other specified disorders of female genital organs Bed rest was ordered until delivery. The following are scenarios most-commonly asked about by attendees during question-and-answer sessions while teaching OB/GYN. 5 Stroke. If the physician only interprets the results and/or operates the equipment, append modifier 26 Professional component to identify the physician’s services. 108 lbs. Told to go to the ER if any signs of vaginal bleeding. Physical exam significant for occipital-parietal flattening on the right side (plagiocephaly) and mild torticollis. on Five Common OB/GYN Scenarios Reveal Coding Answers, Five Common OB/GYN Scenarios Reveal Coding Answers, Hospital Coding: It Isn’t Just for Inpatients. • add-on code reported in addition to code for the technical service provided. 789.03 Abdominal pain, right lower quadrant Scenario #5 - CODES Diagnoses (Primary) V25.41 - Surveillance of previously prescribed contraceptive pill 595.9 Cystitis, unspecified V72.31 Routine GYN examination V74.5 Special screening examination for venereal disease V76.2 Screening for malignant neoplasms of cervix (PAP) V72.41 Pregnancy exam or test, negative result This article highlights some of the new features in coding obstetric cases with ICD-10-CM/PCS. To capture pregnancy diagnosis codes correctly, documentation must specify the type and trimester of the pregnancy, as well as all related, present co-conditions in the mother. When reporting endometrial ablations, consider also: With an aging population (and increased public awareness), urinary incontinence is no longer a forbidden topic. Last PAP exam 8 months ago, normal. 28 year female, established patient, presents complaining of a thin, grayish-white vaginal discharge with a noticeable fishy smell accompanied by vulvar itching. Z87.42 Personal history of other diseases of the female genital tract, 611.72 Lump or mass in breast By Peggy Stilley, CPC, CPC-I, COBGC, ACS-OB. Bimanual exam – no pelvic tenderness, uterus smooth, uterus and adnexa are normal in size, ovaries not palpable. CPT® 2010 offered several revisions to urodynamic testing codes, as well as new and “resequenced” codes. The closest code would be 59350 (Hysterorrhaphy of ruptured uterus) for the laceration of the uterus. The following are scenarios most-commonly asked about by attendees during question-and-answer sessions while teaching OB/GYN. Coders must educate themselves: Know which services need an Advanced Beneficiary Notice (ABN), and whether modifiers are required for payment or are informational only. The Canadian Institute for Health Information (CIHI) is an independent, not-for-profit organization that provides essential information on … 51726 Complex cystometrogram, calibrated electronic equipment As there is a positive family history for breast cancer denoted with the three sisters identified as BRCA positive, the documentation supports the patient’s susceptibility to a malignancy of the breast. No family history of ovarian or cervical cancer. Reports continued fetal movement, no contractions, and no vaginal bleeding. ACLS Megacode Scenario Simulations Put your ACLS skills to the test with these timed megacode scenarios. Providing the patient history can justify additional diagnostic tests (such as the ultrasound here). A Guide to Obstetrical Coding . +51797 Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure). With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. It must tell a story giving a clear picture describing the difficulty encountered in the procedure. Begin Megacode 4 . Pap smear performed. Respiratory: Lungs clear to auscultation. There are O codes indicating that a condition in any other body system is impacting the pregnancy. When performing a thermal (heat) ablation, options include loops, roller balls, etc. A.) Providing a detailed description of the pain characteristics is important as well. Intrauterine pregnancy, twins, 33 weeks with premature rupture of membranes, and onset of labor three hours later. 6 . conditions that could affect a future pregnancy, and that may be amenable to intervention. It is the provider and staff’s responsibility to let the patient know the service may not be covered, or the service has frequency guidelines. Engaged in sexual activity before the age of 16; Had multiple sexual partners (more than five in a lifetime); A history of a sexually transmitted disease (including the human papillomavirus and/or HIV infection); and/or. Coding options also are sensitive to timing of these conditions, reflecting that preeclampsia, eclampsia, and HELLP usually occur during the second or third, The American College of Obstetricians and Gynecologists (ACOG) published a practice guideline for pregnancy induced hypertension in 2013 which includes a revision of the criteria for preeclampsia. Antepartum Care Only – 4 to 6 visits – use CPT code 59425 & 1 unit Antepartum Care Only – 7 or more visits – use CPT code 59426 & 1 unit Postpartum Care Only – use CPT code 59430 Note: For other scenarios, refer to the CPT manual for the correct coding. Coding Scenario #1 A fffifteen year old flfemale with her first pregnancy developed placenta previa in her 35th week. Patient counseled on pain relief exercises. Positive family history for breast cancer – mother and all three sisters. Family history positive for hypertension, migraines. Vaginal exam: Cervix fingertip dilated and 75% effaced. ICD-9-CM Diagnosis Codes There are separate codes for left and right breast diagnoses. are of childbearing age and have had an examination indicating the presence of cervical or vaginal cancer or other abnormalities during any of the preceding three years; or National Correct Coding Initiative (CCI) edits apply to Medicare. RLQ is tender to palpation. When coding, consider all documented factors such as current and pre-existing conditions, trimester, and age. A high-risk patient is one who has: For all other woman, defined as “low risk,” Medicare will pay for a BPP exam every two years. LMP: occurred 2 weeks ago, normal cycle for her. In the scenario above for this patient with bacterial vaginosis, refraining from intercourse was recommended by this physician. About CIHI . As with all coding, remember to imagine how the stor Ann Zeisset, RHIT, CCS, CCS-P, is an independent consultant on ICD-10-CM/PCS. • Code Z79.4, Long -term (current) use of insulin, should also be assigned if the diabetes Other Impacts 21 year old female G2P1001 with RLQ abdominal pain1 for the last 6 months. Z15.01 Genetic susceptibility to malignant neoplasm of breast, 642.43 Mild or unspecified preeclampsia, antepartum condition or complication The rationale for abnormal findings in this encounter is based on the presence of the breast lump. Pelvic shows cervical motion tenderness and adnexal tenderness on the right. History of reflux, slow weight gain, head tilt to left. Using ICD-9 codes, Pap smear coding may vary by payor. Having her typical migraine now. V76.2 Routine screening pap test, intact cervix CCI does not allow the provider to bill separately for anesthesia. Under Pruritis, vulvar that codes to L29.2, ICD-10-CM Has only one generic immunization code, © 2021 Practice Fusion, Inc.  |  Site Map  |  Terms  |  Privacy Policy  As an add-on procedure, 51797 may be reported with 51728 or 51729, which include bladder voiding pressure only. • If the patient was previously diagnosed with a high risk this Abdomen is soft. The clinical concepts for OBGYN guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios. Physical exam significant for occipital-parietal flattening on the right side (plagiocephaly) and mild torticollis. Providing the patient history can justify additional diagnostic tests based on the patient’s risk (such as the fine needle aspiration). But it is not what they are hoping for. 3. Moderate activity 3-5 days per week. 4. Additional codes can be used from other categories in conjunction with maternity codes to further specify the condition(s). Admits to frequent douching and bubble baths. No history of STD. Z23 Encounter for immunization, Index to Diseases for ICD-10-CM under the word itching states “see also Pruritis”. As the clinical status for this patient is not known, it does not have right versus left, e.g. Code O99.89, Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium, R05, Cough, R50.9, Fever, R06.02, Shortness of breath and Z20.838, Contact with and (suspected) exposure to other viral communicable diseases. Vital Signs: BP 150/90, T 99.6°F, P 100, R 30. Vital Signs: BP 128/64, T 98.7°F, Ht. Long time history migraine headaches. Rhythm is regular. With the new terminology associated with ICD-10-CM codes this point will need to be assessed and confirmed so correct code assignment can occur. There are different diagnosis codes for each. Mild right ovarian tenderness. We are looking for thought leaders to contribute content to AAPC’s Knowledge Center. In ICD-10-CM abdominal tenderness is differentiated to address the rebound characteristic with different codes. Place of service is critical to reimbursement. L29.2 Vulvar, pruritis 2. For instance, billing 58356 in your office renders 45.55 relative value units (RVUs), while the same procedure performed in a facility is valued at 9.71 RVUs. However, no provider would consider abdominal pain in pregnancy unrelated. Codes under subcategory O99.31, Alcohol use complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses alcohol during the pregnancy or postpartum. ICD-10 provides distinct coding options for the life-threatening HELLP syndrome to be coded as both a variant or complication of preeclampsia or eclampsia. 1. Voiding pressure studies may measure pressure either just in the bladder or in the bladder and abdomen simultaneously (as described by 51797). This was very tedious given that the adhesions were so dense and there was not a good operating plane and this made the dissection very difficult.” Is the patient’s diabetes the cause of the UTI? Capture that information as appropriate in your note. As there is no indication of previous episodes. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented. ICD-10 differentiates from ICD-9 in clinical terminology to describe preeclampsia as mild to moderate, severe, or unspecified. For example, an obstetrics office could bill CPT code 59400 to cover office visits, a vaginal delivery, and postpartum care, as opposed to separate codes for individual visits or separately billing the antepartum period, delivery, and postpartum period. Previously, she was a corporate coding manager for a large healthcare system and has more than 30 years experience as a HIM Director and coding consultant. About CIHI . Lysis of adhesions may be billed separately—either by reporting a separate CPT® code (see below) or by adding modifier 22 Increased procedural services to the primary procedure code—depending on the adhesions’ extent and based on the procedure’s documentation. Incidental pregnancy is a case when the patient has come for some other concern but has been diagnosed pregnant. Patient had a benign ovarian cyst successfully removed at age 172. Pain is a dull ache. Overall, global billing for maternity eases the burden for both patient and provider. 698.1 Pruritis, vulvar ICD-10-CM/PCS will capture a greater level of specificity for obstetric coding. Supraventricular Tachycardia. Similarly to ICD-9, ICD-10 describes preeclampsia as a complication of pregnancy which is characterized by hypertension; proteinuria and edema may also be present. Had fewer than three negative Pap tests within the previous seven years. Do you wish you knew some helpful tidbits to ease daunting coding tasks? Per the coding guidelines, codes from Chapter 15 … An overview of coverage and risk criteria may be found on the CMS website at www.cms.hhs.gov/CervicalCancerScreening/. Are you new to obstetrics and gynecology (OB/GYN) coding? Note whether the encounter is for a specific issue or an annual or “general” exam. A full listing of covered HCPCS Level II and ICD-9-CM codes, along with instruction for applying the codes and the minimum exam requirements listed above, is found in the Medicare Claims Processing Manual, chapter 18, sections 30 “Screening Pap Smears” and 40 “Screening Pelvic Exams” (www.cms.hhs.gov/manuals/downloads/clm104c18.pdf). Provided vaginal hygiene pamphlet. Pelvic: External exam-vulvar redness, no vulvar edema and no adherent white clumps present; Speculum exam – vaginal walls pink, cervix intact, closed os, thin gray and foul smelling discharge noted in vaginal canal. The use of the best code may vary by payor according to what services were rendered and the insurance plan’s reimbursement of a well women annual visit versus reimbursement of pelvic and/or clinical breast examinations. Well nourished, well-groomed, A&Ox3, mood and affect calm. Direct admit patient to Labor and Delivery unit to monitor for worsening preeclampsia or preeclampsia complications. Outpatient coding for obstetric (OB) services has become more complicated due to the novel coronavirus (COVID-19) pandemic. Examples of Reporting Antepartum Care Services Relocation of a patient. She and a friend are at lunch celebrating Delia’s birthday. This note intentionally does not include a discussion of STIs or reproductive planning which would be commonly denoted in the evaluation and counseling of a female of this age. Coding Scenario #1 A fffifteen year old flfemale with her first pregnancy developed placenta previa in her 35th week. 4 SVT. Has had an estimated 13 pound weight loss over the past month. Refrain from intercourse for one week after starting. It is important to include the patient history, as this can justify additional diagnostic testing. If the rest of Chapter 15 doesn’t have a specific code, numerous “obstetric conditions not elsewhere classified which are complicating pregnancy, childbirth, and the puerperium… The documentation and context of the pain presentation will determine if additional. Thankfully, John sustained only minor abrasions to … As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA. Given patient history and clinical findings right ovarian cyst is suspected. Like a patient has … 789.63 Abdominal tenderness, right lower quadrant The vertex was presenting at 0 station. Documentation is crucial as the surgeon must describe the adhesions in the same manner that a writer describes a situation in a novel. termination of pregnancy date should be used as the end date/delivery date. ICD-10 increases the alternatives for hypertensive disorders in pregnancy (with or without the presence of proteinuria and/or edema); refer to an official ICD-10 guide for example alternatives. Normal pelvic exam. A secondary code from category F10, Alcohol related disorders, should also be assigned to identify manifestations of the alcohol use. These “real world” examples can help you tackle day-to-day coding challenges in your OB/GYN practice. Bradycardia. Providers may recommend to a patient certain exams, tests, or services that are not a covered benefit (for instance, the physician may recommend a BPP exam for a low-risk Medicare beneficiary at a frequency greater than two years since the previous exam). Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge; Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses; External genitalia (for example, general appearance, hair distribution, or lesions); Urethral meatus (for example, size, location, lesions, or prolapse); Urethra (for example, masses, tenderness, or scarring); Bladder (for example, fullness, masses, or tenderness); Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele); Cervix (for example, general appearance, lesions, or discharge); Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support); Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity); and, Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia, One related evaluation and management (E/M) encounter on the date immediately prior to or on the date of the procedure (including history and physical) once the decision for surgery is made, Immediate postoperative care; including dictating operative notes, talking with the family and other physicians, Evaluating the patient in the post-anesthesia recovery area, Complication following the surgery—unless return to OR, Post-op visits (related to recovery from procedure), Post-surgical pain management provided by surgeon, Miscellaneous services (dressing changes, staple, drain, tube removal, etc; local incision care, etc.). The first guideline is about sequencing priority. Pertinent Labs: U/A 2+ proteinuria +2 glucose. Ventricular Fibrillation. What is the correct way to code for type 2 diabetes and a urinary tract infection (UTI)? CMS does not follow CPT® guidelines, however. In this pregnancy her BPs are ranging from 125/85 to 135/90 at previous prenatal visits. Abdominal pain that will not go away and irregular menses. While rushing for the newest iPhone, John fell down the stairs. Medicare pays for a BPP exam every year for those women who: Private payers may allow this, however; if so, bill for the para-cervical block (64435. A Guide to Obstetrical Coding . Abdomen: Fundal height consistent with 36 weeks, single fetus, vertex and engaged; fetal weight ~ 3,000g, FHR 142 bpm. For example, the following codes are provided for category O25, Malnutrition in pregnancy, childbirth and the puerperium: O25.1, Malnutrition in pregnancy; O25.10, Malnutrition in pregnancy, unspecified trimester; O25.11, Malnutrition in pregnancy, first trimester; O25.12, … EMS unit requested and will transport to hospital. This low risk pregnancy may be billed with a package code if four or more visits were completed before the termination. Patient admits to a history of alcohol dependence2. The higher non-facility reimbursement covers the equipment and administrative costs of running your office. Z3A.36 36 weeks gestation. Many companies produce a variety of equipment to accomplish ablations. When coding separately for adhesions using a dedicated CPT® code, select an appropriate code based on location: For example, significant dense adhesions were dissected from the omentum to the anterior abdominal wall and left pelvic sidewall. Any use of hysteroscope can be billed as a hysteroscopic procedure. • add-on code reported in addition to code for the technical service provided. Were they dense and fiberous? Told to go to the ER if any signs of vaginal bleeding.