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, [...]