Ob-Gyn Coding Alert

Establishing medical necessity is the first and most essential step in third-party reimbursement. Think of it this way: payers want to be sure you have good reasons for providing the medical care for which you are requesting payment. If you perform a diagnostic laparoscopy (56300), the payer wants to know why this specific procedure was necessary. More specifically, they want to be sure the services rendered are consistent with the patients presentation and with generally accepted professional medical standards, that the services are not furnished primarily for the convenience of patient or physician, and that they are furnished at an appropriate level.

So when using a code from the CPT, keep in the back of your mind that the payer may doubt the procedure was necessary until proven otherwise. The payer will be looking at the CPT code and wanting to know the patients exact complaint or condition and how severe or emergent that problem was. The payer will want to know all the facts regarding signs, symptoms, complaints, or background knowledge. Of course, all of these facts have to be substantiated by the patients medical record and may be checked out, but the short way you communicate medical necessity is through the correct use of diagnosis codes. Remember, how you use diagnosis codes is essential to reimbursement.

Diagnosis Codes Must Reflect Fact

The chart should tell you what the code is. Knowledgeable coding consultants continually emphasize that among the thousands of codes in the ICD-9, you must chose the codes that best reflect the complete chart and the picture of what is going on with your patient. For example, a woman in her second trimester of pregnancy presents with multiple varicose veins in her left leg with severe superficial phlebitis. ICD-9 coding for the office visit might appear to include a 454.9 (varicose veins of the lower extremities), 451.0 (phlebitis and thromophlebitis of superficial vessels of lower extremities), and V22.0 (supervision of normal pregnancy). But these three codes do not present an accurate picture of the facts because 454.9 and 451.0 do not document complications of pregnancy, and V22.0 is for the management of a normal pregnancy without complications. Instead, you should use 671.03 (antepartum varicose veins of legs) and 671.23 (superficial thrombophlebites). These codes reflect the complete facts.

On the other hand, if a pregnant patient presents with a problem NOT related to pregnancy, such as flu, code the condition the patient came in with and then use the V code V22.2 for the management of the pregnancy as incidental.

Tip: When the diagnostic statement seems vague and unclear look further into the medical record for more documentation to give you the facts. If necessary, talk to the physician and inquire, but remember, you may only code what is in the chart.

Finding the Right Code

How do you find the right diagnosis code? Its important to not shortcut the process. Heres a brief review. A patient presents with painful urination and blood in her urine for unknown reasons. A cysto is scheduled for a future visit to determine an exact diagnosis, but at this visit, you need to code simply to reflect the facts currently known.

Tip: Dont use codes as a rule out or probable. If there is no firm diagnosis, use the codes that reflect symptoms.

1) Using the description of the problem, go to the alphabetic index of diseases first, and look up what you know. In this case, look up blood and the sub category of in the urine. It will point you to code 599.7. Then go to painful and the sub-category of urination. It will point you to code 788.1. Make sure you look up everything that is reflected in the chart. Dont stop just because you have one code. If the problem is a complication of some other condition, look that up as well. You want to code everything.

Tip: If you have a clear diagnosis, you do not need to worry about coding the symptoms and should only code the diagnosis.

2) Now look up the codes youve found in the numeric tabular index. Look at all the conventions and notes to make sure the code fits. Make sure you add any digits that are necessary to be more specific. Look above at the broad categories the code is under and make sure everything fits. If the chart identifies the condition as acute or chronic, make sure the correct code is chosen when available.

Tip: Review all of the conventions in the coding book you are using. Dont guess. The conventions are there to guide you and may change as books are updated.

Using Multiple Diagnosis Codes on
Claim Forms

Diagnosis codes would be easy if each patients visit could be summed up in one code, but often, as indicated above, there is more than one appropriate diagnosis code, and often a patient presents with multiple problems in the same visit. Remember, the diagnosis codes support the CPT codes. The payer is asking, Why did you do this procedure or provide this service? Therefore, there may be different diagnosis codes for each CPT code on the claim form, and there may be more than one diagnosis code needed to support a single CPT code.

Consider the following example. A 25-year-old GYN patient presents in the office with frequent urination and excessive bleeding. During the visit, it found that the bleeding is vaginal (metrorrhagia), and that the patient has a yeast infection (vaginitis) and a vaginal cyst. The patient is scheduled for a D&C to learn more about the metrorrhagia, and the cyst is removed during this visit.

First, identify all of the diagnosis codes that are important to this visit. In this situation, they would be 626.6 (metrorrhagia), 616.10 (vaginitis and vulvovaginitis, unspecified) and 623.8 (other specified non-inflammatory disorder of vagina). The HCFA 1500 form has four slots for diagnosis codes in box 21. You can put the diagnosis codes in whatever order you want (the order in which you list them in box 21 will not affect your reimbursement). For purposes of this example, we are putting the codes in the following order:

1. 626.6

2. 616.10

3. 623.8

4. (no fourth diagnosis, so nothing needs to be
listed)

Tip: Many patients have numerous chronic complaints and conditions that are not the reason for their specific visit. Code chronic complaints only when relevant to the treatment plan. Remember, you want to be as complete as possible in providing the information for the payer, but you do not want to muddy the waters with codes that do not relate the medical necessity of the services you are coding for.

Next, in box 24, there are two columns: D (procedures, services or supplies) and E (diagnosis code). In column D you should write out the actual codes that tie in with the procedure, service or supply. In column E you should list the corresponding number next to the diagnosis code listed in box 21 (as shown above).

Tip: Here be sure to list the diagnosis code numbers from box 21 according to their seriousness, starting with the most serious and decreasing thereafter. This is where the order of the diagnoses counts to ensure proper reimbursement.

Below is an example of how the above case should be recorded in box 24 of the HCFA 1500 form:

 		D		E  
		99214-25	        1 3 2
		57135                3

Note: the 25 is needed because the removal of the cyst is a separate procedure done on the same day.

Tip: It is not necessary to look creatively for more than one diagnosis to support a CPT code. One is enough, but if more apply you will want them all listed in the event of an audit.