Latest on ICD-9 Code Usage for PCOS from Codify's Ob-Gyn Coder Avoid Downcoding Consultations Example: A woman with irregular menses (626.4, Irregular menstrual cycle) and cystic acne (706.1, Other acne) presents to your ob-gyn at the request of her primary physician. The primary physician suspects ovulatory dysfunction or polycystic ovarian syndrome (PCOS) and would like your ob-gyn’s opinion. After a problem-focused history and exam and some diagnostic testing, the ob-gyn determines that the patient does indeed have PCOS (256.4, Polycystic ovaries). The ob-gyn discusses infertility only as a secondary symptom during the course of the history. After the visit, the ob-gyn sends a report to the requesting physician outlining the findings and proposed course of treatment. Solution: In this case, you should report a consultation based on the extent of service the documentation indicates. Right now, you probably have moderate medical decision making but only a problem focused history and exam.... ...to read the full example and get coding guidelines, fee schedules, LCD and CCI edits related to PCOS in one place, subscribe to Codify's Ob-Gyn Coder.
Take a FREE Trial TODAY. Signs and symptoms coding is the key until you have a definitive diagnosis Too often, carriers refuse a polycystic ovarian syndrome (PCOS) diagnosis because it indicates infertility, and they don't pay for infertility treatments. But you can get paid for treating suspected PCOS because the patient usually has other symptoms.
PCOS isn't simply a fertility problem. Unfortunately, many insurance carriers either don't understand that fact or choose to ignore it.
The problem often arises when an insurance carrier receives a claim listing only a PCOS diagnosis. If the patient has received diagnostic testing or treatment for suspected PCOS, the carrier assumes that the patient is receiving fertility treatment and automatically issues a denial. So by coding the patient's condition as 256.4 (Polycystic ovaries) before you have a definitive diagnosis, you've fallen into a coding trap and effectively denied your practice reimbursement for services rendered to that particular patient. Code the Chief Complaint First If you don't report the initial diagnosis as PCOS, how should you code it? The key is to code the chief complaint. A patient generally doesn't walk into your office and say, I have PCOS. A patient usually walks in and says "I haven't had a period in four months. What's wrong with me?" In that case look to the codes for irregular menses (626.4) or hypomenorrhea (626.1) or other disorders of menstruation (626.8).
PCOS isn't always easily diagnosed and coding the complaints provides certainty. If there's any question whether the patient has PCOS you should code the secondary characteristics.
