ED Coding and Reimbursement Alert

You know the routine: A pregnant patient enters the emergency department (ED) complaining of abdominal pain or vaginal bleeding, and the doctor performs an ultrasound (US). You apply obstetric or pelvic US codes, but you 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.

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, 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 634.3 (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, unspecified), 634.31 (... incomplete), or 634.32 (... complete).

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

If you know 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 US for pregnancy-related conditions, use obstetric codes 76801-76817 regardless of the test results. While the US may expose obstetric conditions, such as an ectopic pregnancy, spontaneous abortion, or a molar pregnancy, it may also reveal conditions unrelated to the pregnancy. "If a finding reveals something unrelated to pregnancy, it is still an ob ultrasound, which includes an evaluation of maternal structures," Witt says.

If you're evaluating a pregnant patient for conditions unrelated to the pregnancy, don't use the obstetric US codes. For example, if you perform a US to check for gallstones on a pregnant patient, you should use an abdominal code despite the pregnancy, such as 76705 (Ultrasound, abdominal, B-scan and/or real time with image documentation; limited [e.g., single organ, quadrant, follow-up]). Or, if you're determining whether the patient has urinary retention, use 76857 (Ultrasound, pelvic [nonobstetric], B-scan and or real time with image documentation; limited or follow-up).

While you may be tempted to apply obstetric codes to all pregnant patients, this strategy will earn you rejected claims. Make sure you know whether the physician ordered the US to evaluate pregnancy-related issues.

If the physician doesn't know about the pregnancy before she performs the US, you should use the nonobstetric pelvic codes, such as 76857. Don't use obstetric codes for ultrasounds evaluating pelvic pain, amenorrhea, vaginal bleeding, or nongynecologic pelvic pathology.

Even when the US reveals a previously unknown pregnancy, the obstetric codes still don't apply.

If your physician already performed a prior US, she may conduct a transvaginal US in order to investigate the same area more thoroughly. For instance, a physician may perform a transvaginal US to obtain a higher-resolution view of the intrauterine structures she has already seen in a previous transabdominal US.

If both a transabdominal and a transvaginal ultrasound are medically necessary, you can code them separately. Remember that the transvaginal code - 76830 (Ultrasound, transvaginal) - doesn't depend on the patient's pregnancy status. However, if done for reasons related to the pregnancy, use code 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) instead.

Because you need the right ICD-9 code to prove medical necessity and to apply for reimbursement, make sure your diagnosis codes match the patient's condition. For instance, if she presents with pelvic pain, use 625.9 (Unspecified symptom associated with female genital organs), or if she isn't menstruating, report 626.0 (Absence of menstruation). Check your local medical review policies if you're uncertain about which diagnosis codes are considered medically necessary conditions for these exams.