Coding Corner: Deliver Pregnancy Ultrasound Payment That's Anything but Routine

Nix Certain US Codes When Patient Presents in ED

You've been down this road before: A female patient enters the emergency department (ED) complaining of abdominal pain or vaginal bleeding, and the doc performs an ultrasound (US). You apply obstetric or pelvic US codes, but don't get paid squat.

To avoid this scenario, find out why the doctor ordered the procedure so you'll know which diagnosis code to choose before you apply routine US codes, says Melanie Witt, RN, CPC, MA, an independent ob-gyn coding and documentation educator based in Fredericksburg, Va.

Diagnosis Reveals Ob or Routine Codes

If the woman presents with pain or bleeding, she may have one of these common obstetric ED indications: intrauterine death (656.4 series), spontaneous abortion (634 series), ectopic pregnancy (633 series), or disorders of the ovary, fallopian tube, and broad ligament (620 series), among other conditions.

Don't fish for a medically necessary code, Witt says. "You don't approach it from the angle of 'What diagnosis can I use,' but rather 'Why did the physician order the ultrasound?' - then assign the diagnosis that fits the reason," she says. "If the patient is pregnant, and the reason for the ultrasound is related to the pregnancy and/or fetus, then you must use the Ob diagnosis as the primary diagnosis."

When the physician hands you the chart, make sure he's written down two key bits of information: the patient's pregnancy status and the symptoms that prompted the US. If the patient is pregnant and the doctor diagnoses a pregnancy-related condition, you'll need fifth-digit specificity on the diagnosis code. The stage of the patient's pregnancy determines which fifth digit you should apply.

For example, if the patient has a spontaneous abortion, you need to know what complicated the pregnancy and how complete the patient's pregnancy was. If renal failure caused the condition, for instance, you would start with 634.3x (Spontaneous abortion, complicated by renal failure). For the necessary fifth digit, you need to classify the pregnancy as unspecified, incomplete, or complete. You'd choose one of these three codes, depending on the physician's determination of the pregnancy stage: 634.30 (Spontaneous abortion, complicated by renal failure, unspec-ified), 634.31 (... incomplete), or 634.32 (... complete).

Also, while the exact requirements vary by intermediary, you usually need to attach the US image to the claim when you drop it.

Use Obstetric Codes Regardless of Results

If you know that the patient is pregnant before you perform the ultrasound, and the US is evaluating pregnancy-related conditions, you must use an obstetric pelvic code such as 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited [e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses), Witt says.

For pregnant patients who need a [...]

- Published on 2003-08-13