Medicare Compliance & Reimbursement

Test your documentation attentiveness with these ICD-9 examples.

Subtle differences in your physician's documentation could radically change which diagnosis codes you should report on a claim for a pregnant patient.

You'll do one of two things:
 • Choose a code from the pregnancy complication category -- even if your doctor isn't the physician managing the pregnancy.
 • Report the condition your doctor is treating, followed by V22.2 (Pregnant state, incidental).
 Scenario: A pregnant patient presents to your practice for the ongoing management of gastroesophageal reflux disease (GERD).
 Check out these documentation examples, and discover which ICD-9 code(s) you should report.

Patient is Pregnant' Means Obstetric Code

Example: Your physician evaluates and manages the patient's GERD complaints. He also notes, "Patient is three months pregnant." What primary diagnosis code should you report to support the E/M service?
Solution: If you said 530.8X (Esophageal reflux), then you are technically incorrect. But, because the physician mentioned the patient is three months pregnant, you should instead look to a code from the 630-677 series.

Why: "The obstetric codes are always primary for conditions affecting the pregnancy," says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M. "This is true whether the physician is managing the pregnancy or managing a separate problem."

Still hesitant? Reporting an obstetric code will not interfere with the patient's ob global package, which is governed by the provider who is giving her maternity care. "Just as a Maternal Fetal Medicine specialist (MFM) can bill separately for visits related to pregnancy care," so can your gastroenterologist, Witt says.

You can report 530.8X as a secondary diagnosis.

Incidental Pregnancy Mention Changes Your Options
Example: In the same scenario, the physician evaluates and manages the patient for her GERD. But instead, he states, "GERD not affected by pregnancy." What primary diagnosis should you report to support the
E/M service?

Solution: In this case, you should report the GERD diagnosis (530.8X) first. Your secondary diagnosis should be V22.2. This code indicates, "Oh, by the way, the patient is pregnant," says Lana Flatt, CPC, veteran coder at a physician practice in Cookeville, Tenn.

Why: "The physician had written the condition was incidental to pregnancy," Witt says. "In other words, this condition did not complicate the pregnancy nor the management of the mother or fetus."
Get to Know These Guidelines
 If you have a question about this rule, go straight to the source. The ICD-9-CM Official Guidelines Section I (C)(11)(a)(1) state:
 "Obstetric cases require codes from chapter 11, codes in the range of 630-677, Complications of pregnancy, Childbirth, and the Peurperium. Chapter 11 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 11 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code V22.2 should be used in place of any chapter 11 codes. It is the provider's responsibility to state that the condition being treated is not affecting the pregnancy."
 Best bet: Make sure everyone in your practice is on the same page. If your physician fails to note the pregnancy is incidental, your best bet is to apply a code from the 630-677 series.