Internal Medicine Coding Alert

Question: What is the diagnosis code for a 4-week-old baby brought in when its umbilical cord fails to fall off? We used the appropriate office-visit code with several different ICD-9 codes, but the insurance company is denying, stating that the complication is associated with pregnancy.

California Subscriber

Answer: Reimbursement is based on CPT procedures and services, not on the diagnosis codes. But the reimbursement for services and procedures depends on whether medical necessity has been established by applying the correct ICD-9 codes, says Cindy McMahan, CPC, an independent coding consultant in Albany, Wisc. These codes tell the payer why the services or procedure was performed. Payers are closely monitoring diagnosis codes. You must be specific about problems or symptoms. If coding is not carried to the highest level of specificity, payment may be denied or reduced.

The diagnosis code for a four-week-old newborn with an umbilical cord that has not fallen off is 762.6 (other and unspecified conditions of umbilical cord; including short cord, thrombosis, varices, velamentous insertion and vasa previa, excludes infection of umbilical cord [771.4] and single umbilical artery [747.5]). This code is listed in the 760-779 section of codes, which indicates conditions originating in the perinatal period. This is probably why the insurance company is denying payment. Most likely they are trying to bundle the visit with the pregnancy care provided by the mothers ob/gyn. CPT guidelines stipulate that medical complications of pregnancy should be billed using the evaluation and management codes or medicine section codes.

Complications of pregnancy or delivery are not included in the ob/gyns delivery service or postpartum care service. Surgical complications of pregnancy would be billed with codes from the surgery section of CPT. Submitting documentation along with the claim form may help the payer understand the situation more clearly. A letter reminding them of the CPT guidelines also might be helpful.