ED Coding and Reimbursement Alert

Do you know the “N” and “O” codes that pertain to these systems?

The first quarter of ICD-10 coding is behind us, and ED coders continue to learn the granularity needed to code to the greatest level of specificity. This month, we will take a look at some common OB-GYN problems that are frequently treated in the emergency department and pose a challenge for many coders.  Some of the most common presentations are urinary tract infections, pregnancy complications and vaginitis, says Caral Edelberg, CPC, CPMA, CCS-P, CAC, CHC, Chief Executive Officer of Edelberg and Associate in Atlanta, GA

FYI on the UTI, Be Specific!

Under ICD-10, urinary tract infection codes provide a high level of specificity.  Coders must depend on provider documentation to code correctly, or they will be left with “unspecified” that could impact payment.  Look for chart documentation that characterizes the cystitis as acute or chronic, and whether hematuria is mentioned, Edelberg adds.

Urinary Tract Infection, Cystitis Codes

• N30.00 — Acute cystitis without hematuria
• N30.01 — Acute cystitis with hematuria
• N30.10 — Interstitial cystitis (chronic) without hematuria
• N30.11 — Interstitial cystitis (chronic) with hematuria
• N30.20 — Other chronic cystitis without hematuria
• N30.21 — Other chronic cystitis with hematuria
• N30.80 — Other cystitis without hematuria
• N30.81 —Other cystitis with hematuria
• N30.90 — Cystitis, unspecified without hematuria
• N30.91 — Cystitis, unspecified with hematuria
• N39.0* — Urinary tract infection, site not specified

*Always consider codes with a higher degree of specificity and code it first, warns Edelberg.

Don’t Forget To Include the Current Trimester Documentation on Pregnancy Diagnoses

When treating pregnant patients in the ED, documentation of trimester is required.  The determination is calculated from the first day of the last menstrual period and is documented in weeks.  The definitions of trimesters are:

1. First Trimester is less than 14 weeks, 0 days
2. Second Trimester is 14 weeks, 0 days through 27 weeks and 6 days
3. Third Trimester is 28 weeks through delivery

Consider the following ICD-10 code examples:

• O26.851 — Spotting complicating pregnancy, first trimester
• O26.852 — Spotting complicating pregnancy, second trimester
• O26.853 — Spotting complicating pregnancy, third trimester
• O26.859 — Spotting complicating pregnancy, unspecified trimester

Patients presenting to the ED with suspected abortion represent a bit of a challenge for coders, as rules have changed under ICD-10.

The timeframe for a missed abortion rather than fetal death has changed from 22 to 20 weeks.  An elective abortion is described as an elective termination of pregnancy. 

The O03 (Spontaneous abortion) series references “incomplete abortion”, so you will need to look for documentation of that as the correct diagnosis. There are four spontaneous abortion definitions in ICD-10 and coding professionals should work with the providers to assure documentation addresses the following as appropriate, says Edelberg.

ICD-10 requires that providers document the intent of the encounter which includes the following:

1. Type of encounter
2. Complication (any abnormal findings on examination)

Include Preexisting Conditions and Substance Abuse If Known

Complications of pregnancy require documentation of increased specificity.  Documentation will need to identify any pre-existing conditions, if known, as well as any pregnancy-related conditions.  Attention to the details of the patient’s condition (pre-existing before pregnancy); the trimester in which the pregnancy-related condition developed; and any causal relationship between the pregnancy and the complication needs to be addressed, Edelberg explains.

Unfortunate situations are common in the emergency department and alcohol use, substance abuse and tobacco dependence during pregnancy are no exception.  These conditions require increased specificity and should include the mother’s use or non-use of tobacco, alcohol and/or substance abuse along with the associated risk to the child, if known.  Secondary codes such as those from category F17 (Nicotine dependence) or Z72.0 (Tobacco use) should be assigned when associated with category O99.33, smoking that complicates pregnancy.  Secondary codes from F10 (Alcohol related disorders) are required when codes in category O99.31 (Alcohol use complicating pregnancy…) are used. Examples include O99.311 (Alcohol use complicating pregnancy, first trimester) or O99.331 (Smoking [tobacco] complicating pregnancy, first trimester), Edelberg explains.

Check the Cause and Duration When Coding Vaginitis

Vaginitis is a common ED gynecological complaint. There are several alternative ICD-10 choices to consider depending on the level of detail provided by the ED provider:  N76.0 (Acute vaginitis), N76.1 (Subacute and chronic vaginitis), N76.2 (Acute vulvitis), and N76.3 (Subacute and chronic vulvitis).  If there are no indications of previous episodes or ongoing care for the problem, acute vaginitis is coded.  Bacterial vaginosis is not generally associated with soreness, itching or irritation so if these conditions exist they are coded separately, says Edelberg.