Ob-Gyn Coding Alert

Recently we have had patients come in with urinary incontinence and ask for nonsurgical intervention, says Tonia Shoulders, RN, of Midwest Ob-Gyn Association, St. Louis, MO. Our office plans to initiate a program of nonsurgical treatments but we need to be sure we can be reimbursed for the therapies and time involved.

Understanding the Problem

Female urinary incontinence is a condition with severe economic and psychosocial impact, and it is not just a geriatric problem. Its prevalence in healthy middle-aged women, according to a 1995 study published in Clinical Obstetrics and Gynecology, is as high as 30 percent and may be as high as 47 percent among women who exercise. The cause of urinary incontinence is usually attributed to three common types: stress (625.6), urge (788.31) or flow (788.34). These conditions, especially stress incontinence, may be associated with pelvic organ prolapse and pelvic floor defects as a result of gynecological surgery; vaginal births; underlying neurologic, gastrointestinal, or pulmonary disease; smoking; obesity; and occupational and recreational factors. In many cases these conditions are treated with surgery.

Patty Kulpa, MD, a sports gynecologist and urogynecologist from Gig Harbor, WA, states in an article in The Physician and Sports Medicine, that often, nonsurgical treatment is effective for urinary stress incontinence. Once an appropriate medical, gynecologic and urologic history is taken and a thorough examination is performed, the patient and physician may choose a course of treatment and management that does not include surgery. According to Shoulders, these nonsurgical treatments may include a variety of approaches, such as counseling, exercise teaching, use of mechanical devices, pharmacological agents, biofeedback programs and electrical stimulation. These treatments present a variety of challenges for the ob-gyn coder.

Counseling and Exercise and Biofeedback Training

One of the most common conservative treatments for incontinence is to educate the patient in pelvic floor rehabilitation through awareness and instruction in doing exercises. A common exercise known as Kegel exercises increases the muscle volume of the pelvic floor and develops stronger reflex contractions following a quick rise in intra-abdominal pressure (the precipitating factor in stress incontinence). However, many women lack an awareness of these muscles and do not know how to contract their pelvic floor muscles and perform the necessary exercises. According to Shoulders, more than a brief verbal explanation or educational pamphlet is needed to assist women in developing an exercise program. Along with exercise training, the patient is also instructed in the use of biofeedback techniques. Shoulders says that in many practices this counseling and training service will be provided by nurses.

If the nurse is providing incontinence counseling, it may be billed as a skilled nursing office visit, coded simply with the office visit codes 99211-99214, depending on the complexity of the [...]