Ob-Gyn Coding Alert

ICD-9 has many codes for conditions in a pregnant patient some that complicate pregnancy and others that do not. Choosing the right diagnosis will make the difference in whether your practice is paid for extra visits and tests during or after the antepartum period.
 
The ICD-9 code group 640-648 (complications mainly related to pregnancy) includes problems that arise during a pregnancy (642.4x, mild or unspecified pre-eclampsia) or problems already present in the mother that complicate the pregnancy, such as diabetes (648.0x, diabetes mellitus). When a problem such as one of these is clearly complicating a pregnancy, coding the diagnosis is fairly straightforward. But when problems arise that may or may not impact the health of the mother or fetus or the outcome of the pregnancy, choosing the right code or codes and listing them in the right order becomes more complex.

Related or Unrelated?     

Often, complications arise in a pregnancy that may or may not affect the health of either the mother or the fetus, yet the problem or complication is serious enough to require extra monitoring by the physician. That often means extra tests or office visits, above what most carriers consider normal for a global maternity package. The physician must code the complication before it threatens the pregnancy and regardless of whether it becomes a threat during the antepartum period or labor and delivery.
 
Katie Chaffee, CCS, coding specialist for Franciscan Medical Group in Tacoma, Wash., presents the case of an ob/gyn patient who came in for a regularly scheduled visit as part of her global antepartum care. The physician discovered that she had a very enlarged thyroid gland, although it was not an immediate threat to the pregnancy. In a situation like this" " Chaffee asks "does the physician have to state in the record that the problem is complicating the pregnancy in order to use a code from the 640-648 series?" Specifically the code for an enlarged thyroid during pregnancy is 648.13 (thyroid dysfunction; antepartum condition or complication). But Chaffee wonders if 240.9 (goiter unspecified) the non-ob code for thyroid dysfunction isn't the better choice when submitted with V22.0 (supervision of  normal first pregnancy).

Intention is Key

Obstetric ICD-9 coding rules published by the American Hospital Association's Coding Clinic in the fourth quarter of 1993 state that the pregnancy code supercedes all other codes but only if the condition being reported is complicating the pregnancy. So if Chaffee's physician records that the condition is complicating the pregnancy the practice will probably not be able to bill the visit outside of the global package unless at the end of the pregnancy the patient was seen more than 13 times the standard number of visits for a normal global pregnancy. The visit would be coded as a normal part of the global package but the note for that day's visit would include 648.13. Only when required office visits to monitor the thyroid condition exceed the normal number of global antepartum visits could the practice look to charging for additional fees but any diagnostic or laboratory tests ordered as part of this monitoring can be billed at the time they occur.
 
If the physician indicates that the problem is not related to the pregnancy and not complicating the pregnancy Chaffee's patient would be coded with the non-ob code for the enlarged thyroid (240.9) with a secondary code of V22.2 (pregnant state incidental). Codes V22.0 or V22.1 (supervision of other normal pregnancy) would not be used here because the pregnancy is not the primary diagnosis.
 
The same principle applies if the patient had a urinary tract infection (UTI) which is common in pregnancy. If the physician considered the UTI as unrelated to the pregnancy the visit would be billed at the appropriate E/M level for an established patient (99211-99215) linked to diagnostic codes 599.0 (urinary tract infection site not specified) and V22.2.
 
Modifier -25 would be added to the E/M service only if this problem was managed at a regularly scheduled antepartum visit. Otherwise no modifier is added to the service.
 
Note: Modifier -24 would not be used because it describes an unrelated E/M service during the postoper-ative period so the antepartum period would not qualify.   

If the physician thinks the UTI is a result of pregnancy or is complicating the pregnancy it is coded as 646.63 (infections of genitourinary tract in pregnancy; antepartum condition or complication) without a V22 code.
 
This visit would probably be considered part of the global package. Also if the thyroid condition or UTI occurred before the pregnancy the physician can bill for the visits to treat these problems at the time they occur. If they are a complication of pregnancy the practice will have to wait until 13 visits occur to bill for the extra visits.
 
In both examples the principle is to let the physician decide but make sure he or she understands what the difference will mean when coding for certain extra services outside the global period.

When a Concern Becomes a Problem

When an ob/gyn patient has complications early in the pregnancy they may not pose an immediate threat to the mother or fetus. But as weeks or months pass the problems may become worse. According to Wanda D. Brown CPC president of ProActive Coding Service a physician coding and compliance firm in Jacksonville Fla. an enlarged thyroid may cause fatigue dry skin hair loss weight gain constipation sensitivity to cold and failure to produce sufficient calcium for both mother and fetus.
 
A UTI that does not clear up with antibiotics can cause major problems in a pregnancy such as pyelonephritis which in turn can cause premature birth infant mortality and later chronic kidney disease. Even if the UTI does not progress to this state an uncontrolled infection can still cause premature labor and infants with low birth weight.
 
Either the thyroid dysfunction or the UTI could require additional visits and testing. Since most ob/gyn offices are not equipped to do complicated lab tests blood would be drawn in the office and sent to an outside lab. Tests such as 84443 (thyroid stimulating hormone) 84436 (thyroxine; total) and 84479 (thyroid hormone [T3 or T4] uptake or thyroid hormone binding ratio [THBR]) are ordered from the lab and the practice can bill for the blood draw using 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]).
 
The hyperthyroidism will likely be managed with drugs that counteract the production of the thyroid such as a propylthiouracil a drug available as a generic compound only until symptoms decrease. When tests are billed to the carrier by the lab the diagnostic code accompanying them would be from the 640-648 series rather than the non-ob code.
 
With the UTI the physician will likely order more frequent urinalysis such as 87086 (culture bacterial; quantitative colony count urine) or 87088 (culture bacterial; with isolation and presumptive identification of isolates urine). Although the practice may be able to bill for the conveyance using 99000 (handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) the only certainty in billing is the extra visits required to monitor the UTI.
 
In these cases when the ob chapter codes are used to diagnose the problem the practice will have to wait until 13 visits have been completed before billing for any of the extra service. It does not matter whether the physician treats the patient or refers her to a specialist. If the patient developed the problem because she was pregnant and now has to be monitored to keep it from affecting the pregnancy the ob chapter codes apply and the practice must wait to bill.