Ob-Gyn Coding Alert

Don't just watch for updates - be sure you select proper 4th, 5th digits

If you've received a denial stating the service the ob-gyn provided was "medically unnecessary," you've got one problem: your diagnosis coding. Protect yourself from time-consuming appeals with these important specificity requirements.

Many coders neglected to pay the necessary attention to ICD-9 coding until recently "because Medicare was the only carrier that cared if you used the correct codes," says Victoria Jackson, owner of Omni Management, which provides practice management services for 15 medical offices in the Los Angeles area.

Check for These Helpful Guides

You should always report the ICD-9 code that provides the highest degree of accuracy for the condition the ob-gyn is treating. "That 'highest degree' means that you should assign the most precise ICD-9 code that most fully explains the narrative description of the symptom or diagnosis," says JoAnn Baker, CCS, CPC-H, CPC, CHCC, an education specialist in East Orange, N.J.

Rely on your ICD-9 manual's instructions to ensure you're listing complete ICD-9 codes. If you see a check mark with a "4th" or "5th" next to a code, ICD-9 is telling you that the code requires a fourth or fifth digit. Anything less would result in an incomplete claim.

Example: If an ob-gyn patient who is not pregnant presents with vulvitis NOS, you're likely going to report 616.1x (Vaginitis and vulvovaginitis). But coding shouldn't stop there. You've got to add "0," which means "vaginitis and vulvovaginitis, unspecified," says Jennifer Ohmart, medical billing, coding, and insurance specialist at Anne Walters, CNM, Susan McConaughy, CNM, Amy Wallace, CNM, Wayne Furr, MD, Ob-Gyn, in Englewood, Colo.  "NOS" means "not otherwise specified," which is why 0 is the correct fifth digit.

If the patient is pregnant and has vulvitis NOS, you'll report 646.6x (Infections of genitourinary tract in pregnancy) and add a fifth digit (0-4) to represent the current episode code such as 1 for "delivered, with or without mention of antepartum condition." 

Such careful coding is especially necessary for the ob-gyn treating a pregnant patient, because the ob-gyn is likely treating the complications of the pregnancy rather than caring for the pregnancy itself. Without the proper ICD-9 to indicate the complications, the insurer would likely rule an ob-gyn's care incidental and part of the global ob package.

Key idea: If the ICD-9 code is not as specific as carrier rules require, the claim may be rejected for lack of medical necessity and/or a truncated code, says Margaret Lamb, RHIT, CPC, coding expert in Great Falls, Mont.

Always Advance Your New Code Knowledge

Another factor that results in piles of denials is the use of expired diagnosis codes.

For example, as of Oct. 1, 2005, you need to report the four-digit code V72.42 (Pregnancy, confirmed) when a patient comes in to validate that she is pregnant. Hopefully this will signal to payers that this visit with the ob-gyn is not part of the global ob packages, Ohmart says.

That's different from how you code this now. If a patient came to your office today to confirm pregnancy with an in-office test or ultrasound, you would code the test using missed period (626.8) and pregnancy (V22.0, Supervision of normal first pregnancy; or V22.1, Supervision of other normal pregnancy), says Cheryl A. Lewis, CPC, office manager at Zia Ob-Gyn in Yuma, Ariz.

By staying current on your codes, you'll be able to code more accurately, increase your chances of proving medical necessity and decrease your chance of a denial.

Note: For more info on the 2006 ob-gyn changes, see "Expand Your V Code Know-How By 3 - 3 Additions, That Is" and "Factor in New Fetal Reduction, Peritonitis Codes or Face Denials" in the July 2005 Ob-Gyn Coding Alert. You can also send e-mail to me at suzannel@eliresearch.com for a free PDF of all 2006 ICD-9 changes.

Pinpoint Possible Pitfalls

Before sending out a claim with a three-digit diagnosis code, you should double-check the code, Jackson says. Three-digit diagnosis codes raise payers' eyebrows, she says, because there are very few ICD-9 codes that don't require at least four digits. Payers realize this fact and are examining ICD-9 codes to ensure they're appropriately specific.

Translation: "Medically unnecessary" can often be the result of a three-digit code that didn't make the grade because a four- or five-digit is required.

Be Specific Now to Stay Ahead of the Curve

With the number of codes growing every year (and the prospect of a much-more-specific ICD-10 in the future), you must keep your superbill updated, Lamb says. She notes that many offices have quite a few truncated codes on their bills, causing coders and billers to need to go back to the chart or the physician to find out what the fourth or fifth digit should be.