Ob-Gyn Coding Alert

"Ectopic pregnancy has been increasing in recent years, and recent statistics show it now occurs in one out of 60 pregnancies. This increase is thought to be related to an increasing incidence of chlamydia, gonorrhea and other pelvic infections. For those patients who require intervention, the laparoscopic treatment of ectopic pregnancy with salpingectomy (59151) is still the most common, albeit expensive, treatment. But recently, more ob/gyns are considering using the anticancer drug methotrexate as a viable, nonsurgical alternative to salpingectomy.

Methotrexate kills growing cells of the placenta and induces abortion of the ectopic pregnancy. Several new studies -- including a 1997 report in Lancet -- reaffirm that methotrexate may be an effective alternative to surgery. Commenting on the study for Reuters, James Liu, MD, professor of obstetrics and gynecology and head of reproductive endocrinology at the University of Cincinnati, said, Basically, what this study says is you can use either (methotrexate or surgery). From a cost-effective point of view -- and this is something they (the study) didnt address -- if they are both equally effective, and laparoscopy costs you $10,000, lets say, and methotrexate costs you $1,000 for monitoring and ultrasound, which one would you use? They both end up with the same tubal patency rate, they both end up with similar re-operation rates for persistent hCG levels in some of the folks that fail.

Long Follow Up with Methotrexate

While methotrexate is less expensive, a long follow up period is required, and that is precisely what prompted Michael Anthony, MD, FACOG, of Cary Obstetrics and Gynecology, PA to ask what codes should be used for treating ectopic pregnancy with methotrexate. Because of the more intensive follow-up and risk, I feel I should have a special code for this extensive treatment. Use of methotrexate involves a series of office visits to measure hCG levels, possible ultrasounds and numerous phone calls.

Coding for Methotrexate

First of all, its important to note that currently there are no global codes in the CPT for the medical treatment of ectopic pregnancy with methotrexate. Therefore, the physician can only be reimbursed for itemized services such as administration of the drug, successive hCG level tests and other procedures performed. If the methotrexate is administered by the physician following a D&C, a modifier 58 (Staged Procedure) can be added to the injection procedure code (90782). The drug should be billed using either the CPTs all purpose code for supplies (99070) or the HCPCS J code J9260 (methotrexate sodium, 50mg -- which is a common dosage).

In both cases, correct diagnosis codes need to be attached to both the D&C code and the injection code. The D&C should be linked to the ectopic pregnancy code 633.X (not to an incomplete AB code), and the injection should then be linked to the incomplete AB code 634.X1 or 635.X1 (depending on whether the abortion was spontaneous or induced).

Note that using these codes will not provide for reimbursement for telephone contact with the patient, which is part of the necessary follow-up of methotrexate injections. Therefore, the physician currently has three options.

1) Since using this approach to resolving the ectopic pregnancy may be saving the payer a substantial amount of money, and since phone calls are more efficient than office visits, the physician should open a dialogue with the payer to get follow-up phone calls reimbursed.

2) The physician can seek reimbursement from the patient after informing her that the telephone follow up is not covered by her insurance and will be her responsibility.

3) The physician can have the patient come to the office and code for an office visit each time contact with the patient is necessary.

Tip: Because methotrexate is a chemotherapeutic drug, some payers will allow the administration of the drug to be billed using the chemo code 96400 (chemotherapy administration SQ or IM) rather than the 90782 (therapeutic or diagnostic injection). Use of this code, however, will still not reimburse the physician for follow-up telephone calls as the procedure code is for injection only. Also, be aware that many payers may reject 96400 unless it is linked to a diagnosis of cancer."