Ob-Gyn Coding Alert

Editors Note: Although this case focuses on multiple visits to address the problem of infertility, the same principles of coding apply to the accurate reporting of any multiple-visit problem. If you have a case youd like to submit for consideration, please send it via fax, email or mail.

A 27-year-old female patient was sent by her family physician for a consult to an ob/gyn for evaluation of possible infertility. She had been unable to conceive after more than one year of intercourse without contraception.

After a complete work-up on October 4, including a comprehensive history, comprehensive physical examination, and face-to-face review of the medical records, an initial evaluation was planned and carried out. The evaluation included a semen analysis, hysterosalpingogram (HSG), endometrial biopsy, serum progesterone, and review of basal body temperature curve. An endometrial biopsy was performed on the day of the first visit and the HSG was scheduled for three days later at the hospital radiology department.

The patient was seen one week later in the office to review the results of testing and go over the plan of management (the visit lasted 30 minutes). Anovulation was diagnosed, and the patient elects to be treated with six cycles of clomiphene citrate. The day before this encounter, the doctor informs the family physician of his findings over the phone. The family physician tells the ob/gyn to proceed with any necessary treatment.

The patient is seen monthly for office evaluations that confirmed ovulation but failed to achieve conception. On April 25, diagnostic laparoscopy with chromotubation was performed with normal results. The decision was made to try menotropins therapy one week following surgery during an office encounter involving a postoperative check and one hour of face-to-face discussion of treatment options. At this encounter, the patient is instructed how to self-administer the menotropins and is given a supply of ampules, needles, syringes and alcohol wipes, and she watches a video on the preparation and administration of the drug. She calls the office as soon as her period starts two weeks later and she comes into the office the next day for an ultrasound to see if she is ready to start therapy. She is instructed to start the menotropins therapy three days later and is scheduled for daily blood work with the outpatient lab. The physician evaluates daily lab results to determine the amount of menotropins she should take each evening. The patient calls the office daily to get dosage instructions from the physician and to find out if an ultrasound will be required the next day. She has two office ultrasounds to check for follicles. These are performed on May 25 and May 30. The patients cycle lasts 11 days. On May 30, the ultrasound confirms she is ready for her injection of human chorionic gonadotropin (HCG) and it is administered at this visit. A progesterone blood test is done to confirm ovulation 24 hours after HCG injection at the outpatient lab. At that point, the patient is instructed over the phone on when and how often to have sexual intercourse. The woman conceives.

Coders Notebook

The primary goal of coding this case, regardless of whether or not these services will be reimbursed, is to correctly report everything that was done for this patient. Originally, this womans office care was coded as one new patient visit and the physician billed once for the HCG supply and 11 times for the menotropins supply. The surgery, HSG and office ultrasounds were coded correctly, but the office did not code for any follow-up visits or telephone calls. Now for the correct coding.

The first visit might be billed as a level 4 or a level 5 consult (99244 or 99245), because the womans primary physician requested an evaluation of the problem, and the
ob/gyn rendered an opinion and communicated the finding. The level of consult will depend on the documentation of medical decision-making (moderate vs. high complexity). In this case, a comprehensive history and a comprehensive exam were performed. A modifier -25 can also be added to the consult code because an endometrial biopsy (58100) is done during the visit. If the three criteria for a consultation are not met (1. requested opinion of specialist; 2. patient reviewed by specialist; 3. reported findings to primary care physician), the first visit will be coded as a level 4 or 5 new patient outpatient encounter (99204 or 99205).

Everything done in this first visit is linked to the single diagnosis code of 628.9 (infertility, female, of unspecified origin) because the physician is unclear
why the woman cannot conceive. This is an example
of using the modifier -25 with only one diagnosis code.

At the next encounter, the office coded the HSG cor-
rectly by reporting only 58340 for the injection procedure. No modifier is required for code 58340 because the previous surgical procedure (endometrial biopsy) has a 0-day global period. A radiologist at the hospital performed the radiologic interpretation and report. No evaluation or management service was documented that day. The diagnosis code for this visit is also 628.9 because the physician is still performing diagnostic tests.

The second visit to the office is coded as a level-4 return office visit (99214), because the physician is taking over care of the patient and has counseled her for 30 minutes. At this encounter, the physician told the patient that her infertility was due to anovulation, they discussed treatment options, and the patient is given a prescription for clomiphene citrate. Now the diagnosis is more specific, so the coding changes to 628.0 (infertility, female, associated with anovulation).

The patient is seen monthly to confirm ovulation. These visits will be coded based on the level of exam
and medical decision-making that was documented. In general, they would likely be problem-focused or expanded problem-focused in nature, so a level 2 or level 3 E/M service would probably be coded (99212 or 99213).

At the final monthly visit, the physician discusses the patients failure to conceive with the clomiphene citrate and recommends that a diagnostic laparoscopy with chromotubation be performed to evaluate what else might be going on. The patient agrees and this becomes the visit at which the decision to do surgery was made. No modifier will be needed to indicate this, however, because surgery is performed 11 days later. The code 56300 (diagnostic lapa-
roscopy), which is a CPT separate procedure, is reported as the primary procedure with a modifier -59 to indicate that it is distinct from other procedures performed at the same time, and the code 58350 (chromotubation of oviduct) is reported with the modifier -51 added for multiple procedures. Both are still linked to diagnosis code 682.0.

Now, the patient returns for another office visit to discuss the findings of the surgery and treatment options. This visit, while it occurs during the 10-day postop global period for the diagnostic laparoscopy, is more than a simple postoperative visit. Part of the encounter is for an E/M service that is unrelated to recovery from surgery. The level of E/M service will be selected based solely on the parts that were unrelated and a modifier -24 will be added to the code to show that it was an unrelated service during the global period. The office can also bill for the drug and other supplies.

Telephone calls will probably not be reimbursed by the payer, so if you choose to charge the patient for them, be sure she is informed up front what her out-of-pocket expenses may be.

The visit at which the HCG injection was performed can be billed either as 99211 (office visit) or as 90782 (injection), but not both. The code 99211, should, however, be accompanied by a note in the medical chart indicating the service provided. This might include blood pressure and observation following the injection. The ultrasound (76856) done on that day does not need a modifier.

Editors Note: See insert for original claim form and coding corrections.

Article contributors: Expert advice for this case study was provided by the following sources: Melanie Witt, RN, CPC, MA, program manager, Department of Coding and Nomenclature, Amercian College of Obstetricians and Gynecologists, Washington, DC; Evelyn M. Gross, CMM,CPC, NR-CMA, healthcare consultant-accounting firm, Amper, Molitziner & Mattia, NJ; Thomas Kent, CMM, principal, Kent Medical Management, Dunkirk, MD; Dunnihoo, DR Fundamentals of Gynecology and Obstetrics, J.B. Lippincott and Co.; Philadelphia 1990.