Ob-Gyn Coding Alert

"In the world of ob/gyn care, a distinct diagnosis may be hard to pin down, particularly at the time of the patients initial complaint. Signs and symptoms codes can help classify a visit when no distinct diagnosis can be made, and they may boost reimbursement by increasing the level of decision-making for E/M visits.

ICD-9 codes should be used to describe a diagnosis, symptom, complaint, condition or problem of a patient for the medical service or procedure being billed. Although claims adjusters are trained to look for a specific diagnosis, a patient might have a complaint that cannot be diagnosed right away. When there is not a specific diagnosis available to the physician, the ICD-9 signs and symptoms codes should be used to provide medical necessity for a procedure or service. According to Catherine A. Brink, CMM, CPC, president of Healthcare Resources Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., a code or codes from this group can be valid if it most closely describes the diagnosis. But, these should only be used after checking all other options, Brink says.

Sometimes, a definitive diagnosis cannot be reached before lab or other diagnostic tests are returned, so the physician can only record an ICD-9 code of urinary frequency or urinary urgency, for example, even if he or she suspects stress urinary incontinence. In other cases, test results are normal and a diagnosis cannot be determined. For example, a patient presents to the gynecologist complaining of abdominal pain. The physician completes a pelvic exam and Pap smear, and orders an ultrasound. The ultrasound, done three days later when the ultrasound technician is in the office, does not find any abnormalities to explain the pain. The patients pain subsides, and no more follow-up is scheduled, although she is told to make an appointment if the pain returns.

In the absence of a specific diagnosis, practices can use diagnosis codes listed in the Symptoms, Signs, and Ill-Defined Conditions section of the ICD-9 codebook to prove medical necessity for the visit. In this case, 789.0x (abdominal pain [the fifth digit is required to identify location of pain]) could be assigned to the claim. In a gyn practice, however, some of the codes in the genitourinary chapter of the ICD-9 book also refer to symptoms rather than definitive diagnoses. For instance, category 625 includes codes for pain and other symptoms associated with the genital organs. Code 625.9 (unspecified symptom associated with female genital organs), therefore, can be used if the pain is thought to be pelvic rather than abdominal.

Signs/Symptoms Codes Versus Rule-out Diagnoses

Some physicians may be wary of using the signs/symptoms codes because of their years of residence at hospitals, where rule-out diagnoses are allowed and signs and symptoms codes are not used as regularly. Such usage is the norm for hospitals that are paid based on the most severe diagnosis for which the patient receives care during his or her stay, but it does not apply to physician office coding. Physicians in private practice are not allowed to use suspected or rule-out diagnoses. Without a specific diagnosis, they have to use the signs or symptoms that the patient brought to the office and prompted the physician to perform the rule-out test.

A patient may also come to the office with a complaint, but after the examination, the ob/gyn may find nothing wrong. For example, the patient may be referred by a primary care physician (PCP) because of the above-mentioned abdominal pain. However, by the time of the examination, which could be anywhere from one day to a couple of weeks later depending on both the patients and physicians schedules, the patients pain has subsided, and no other symptoms are discovered.

In such a scenario, the sign or symptom (789.0x or 625.9) can still be coded to provide medical necessity for the exam. Of course, if, during the exam, the ob/gyn discovers something more specific, such as a mass that appears to be on the ovary, 789.3x (abdominal or pelvic swelling, mass, or lump [fifth digit to indicate location]) should be reported instead. Although the ob/gyn may suspect a malignancy or an ovarian cyst (620.2, other and unspecified ovarian cyst) neither of these conditions can be coded until either a biopsy confirms malignancy or an ultrasound detects the cyst.

The coding sequence is as follows if we assume the patient was referred by her PCP for a consultation and the physician believes that the patient may have an ovarian cyst:

Visit #1: Code 9924x (office consultation for a new or established patient ...). The diagnostic code is 789.3x (for abdominal mass), 789.0x (for abdominal pain) or 625.9 (for pelvic pain) depending on the physicians assessment of the problem. The physician then orders an ultrasound to discover whether a cyst exists.

Visit #2: Code 76856 (echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete). The diagnostic code is 789.3x, 789.0x or 625.9 if the cyst is not detected until after the ultrasound is complete.

Some payers will insist that only the reason for the ultrasound can be coded, not the findings immediately known to the physician by the end of the patient encounter. Contrast that to the ICD-9 coding rule that states you must code for what you know at the end of the encounter.

Visit #3: Code 9921x (office or other outpatient visit for the evaluation and management of an established patient ...). The physician discusses the ultrasound results with the patient and schedules surgery for a laparoscopic ovarian cystectomy (58662) or an open ovarian cystectomy (58925).

The diagnostic code is 620.2 (other and unspecified ovarian cyst) because the cyst has been detected, but the type of cyst is not known nor can the physician rule out cancer without a biopsy. The final diagnosis on the surgical codes billed will be the results shown on the pathology report after the biopsy, which will identify the type of cyst or the presence of any malignancy.

If there is malignancy, all further treatment of the patient would be linked to the appropriate diagnostic code for the cancer (e.g., 183.0, malignant neoplasm of ovary and other uterine adnexa).

Documentation Can Boost E/M Levels

The physician will normally include a statement in the medical record via a chief complaint or in the history of present illness as to why the patient is coming in. When the reason for the visit is indicated by a symptom or list of symptoms, they can be reported to justify the medical necessity of the visit. However, the medical record for the encounter must match the signs and symptoms code used when billing for the E/M visit. You cannot make up signs and symptoms after the fact. You have to use the signs and symptoms documented in the patients medical record.

Documentation should also identify secondary diagnoses, when applicable. Secondary diagnoses are diseases and conditions that co-exist during an encounter and affect the management of the patients care, explains Wanda D. Brown, CPC, education specialist for University of Florida Jacksonville Physicians Inc. These diagnoses should be sequenced after the primary diagnosis. For example, Brown says, a diabetic patient is seen for abdominal mass. The provider can code the diabetes as a secondary diagnosis, even if he is not managing the diabetes, because this systemic condition will be a factor in his medical decision-making and when prescribing medication.

The signs or symptoms codes may also justify higher levels of E/M services, since the medical decision-making portion of the E/M service is often boosted when the physician has only a sign or symptom to work with due to the undefined nature of the complaint. Often, you can cite medical decision-making of a moderate or high complexity when using signs and symptoms codes because the situation increases the number of diagnoses/management options in the decision-making category. Brown explains that in the case of the patient with an abdominal mass of an as-yet-undetermined nature, higher level E/M coding is legitimate. Any time one is dealing with an unknown mass, she says, I think the provider can justify a higher-level of E/M billing, so long as he or she documents the mass in detail (size, location, color of skin adjacent to mass, due to injury, following birth, etc.).

The other two components of medical decision-making (risk of mortality and morbidity to the patient, and tests ordered and reviewed) are also likely to be higher when there is not a specific diagnosis. When a problem is undiagnosed, it often means the doctor will have to order tests to try to determine the patients problem. After all, a specific diagnosis is less likely to call for many tests than a sign or symptom because the cause of the symptom is unknown and needs to be discovered."