Ob-Gyn Coding Alert

"The ICD-9 manual has two separate sections of diagnostic codes for pregnancy. Understanding when to apply which codes can be the key to greater reimbursement for the supervision of high-risk or otherwise complicated pregnancies.

By simplest definition, V codes are used for the supervision of a normal pregnancy, or the supervision of a high-risk pregnancy when no complications occur. Specifically, codes V22.0 (supervision of first normal pregnancy) or V22.1 (supervision of other normal pregnancy) are about as basic a diagnosis code as you can get for pregnancy.

Other pregnancies, although considered high risk because of potential problems due to the mothers age or reproductive history, for example, are coded as high risk but frequently progress to term with no complications. These circumstances are coded using the V23 (supervision of high-risk pregnancy) family of codes. This category includes codes such as: V23.0 (pregnancy with history of infertility) or V23.81 (elderly primigravida; first pregnancy in a woman who will be 35 years of age or older at expected date of delivery).

High-risk pregnancy codes dont imply that the patient has a problem, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. It only means there is a greater potential for problems. If a high-risk pregnancy progresses satisfactorily, the V code is the only diagnostic code required. For instance, V23.81 is the code for an elderly primigravida. The code alone doesnt imply there are complications in the pregnancy, but it does mean you have to monitor the patient more closely than you might a younger ob patient. Callaway-Stradley says that using the high-risk diagnosis code will help justify any additional visits or screening tests that occur during the pregnancy. For instance, she says, almost every elderly primigravida undergoes an amniocentesis. In most cases, insurers will see that high-risk code, see the code for the amnio and put two and two together, where they might have otherwise balked at paying for an amnio.

When Does High Risk Become Complicated?

The five-digit diagnostic codes come into play in one of two ways: Either the patient presents with a complicating problema history of hypertension or pre-existing diabetes, for instanceor she develops complications during the course of the pregnancy. In this case, its time to turn to the five-digit complications of pregnancy section of the ICD-9 book, which starts with code 634.xx and continues through to code 676.xx.

Just about anything that can happen to a human being [during pregnancy and delivery] is in that coding chapter, says Angela Wood, CPC, CCS, a healthcare consultant at Elliot, Davis and Company, an Augusta, Ga.-based CPA firm that offers medical practice consulting. Its almost like a miniature code book unto itself, specific to pregnant women. It relates to women who are pregnant with a history of hypertension, with pre-existing diabetes or gestational diabetesyou name itits all covered in this section.

Callaway-Stradley urges physicians and coders not to be afraid to use more than one code from the five-digit section when necessary. Physicians are supposed to hone their diagnosis as they learn more about the patients condition, meaning the coding should get more and more specific. But remember, with a complicated ob, the patient may go back and forth from a chronic to an acute condition. The doctor has to bill for what he or she knows and what is being treated on a day-by-day basis. Given Callaway-Stradleys explanation, a patient could be coded as 642.43 (mild or unspecified pre-eclampsia; antepartum condition or complication) during one visit, as 642.53 (severe pre-eclampsia; antepartum condition or complication) on the next, then back to 642.43 on the next visit if the pre-eclampsia lessens in severity.

For practices that specialize in high-risk ob, the five-digit codes are the most prevalent. I worked for an MFM (maternal fetal medicine) practice before my current job, says Wood, so we didnt see many uncomplicated high-risk pregnancies, although its certainly not unheard of. Its just that MFMs dont see too many normal moms. We wound up using the V codes mostly for outcome of the pregnancies (V27.0V27.9) and the five digits for everything else.

Wood also says that when preparing claims for submission, coders can recognize certain procedures as flags. Multiple amnion, ultrasounds and especially non-stress tests are not typical of every pregnancy, says Wood. These are signs to the coder that something more complicated is going on than what you would have in a standard V-code mom.

Correct Coding Sequences

Once you have established the proper diagnosis for your patients symptoms, accurate coding in the correct order is the next step. Although V codes for high-risk pregnancy can be used in combination with the five-digit codes for complications of pregnancy, for reimbursement purposes, according to Callaway-Stradley, this is often a wasted effort. You can use the V codes (for high risk) with the five-digit codes, but it really boils down to what insurance companies want to see, she says. The five-digit pregnancy code should always be listed as the primary one when you submit claims. Sometimes the complications resolve, then you can go back to V codes again. Otherwise, theres no reason to use them in combination. If you follow the absolute letter of the code, it tells you to list the V code second. But most insurers will only pay attention to the first code. If you use both, essentially what youre saying is Here is a complication of a pregnancy (the five-digit) code, and on the next line, this is a high-risk pregnancy (the V code). This is redundant, since you wouldnt have a five-digit code unless you had a high-risk pregnancy.

But Callaway-Stradley also contends that the high-risk V codes can be helpful for practice management. I have seen practices make use of the V codes to track certain conditions, she says. For instance, they might want to do an audit at the end of the year to see how many high-risk pregnancies they treated. While using the five digits is better for billing, adding the V code to the internal paperwork can be useful in the long run, but for different reasons.

So, what will a claim for a high-risk pregnancy with complications look like?

There are two ways to submit the claim that essentially depend on the insurers preference. With most pregnancies, you will be submitting a global ob care code. For example, code 59400 (routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) will be used. With a high-risk pregnancy with complications, its safe to assume that the number of patient visits will surpass the number generally accepted as normal for global care (typically 12-15 visits).

If at the end of the pregnancy you find youve done 20 visits instead of the average, says Callaway-Stradley, you submit claims for those extra visits, using the five-digit codes. An extra ob visit would be reported using the appropriate evaluation and management (E/M) code, linked to the complicating factor diagnosis code, and may look something like: 99213/642.03 (office or other outpatient visit; benign essential hypertension complicating pregnancy, childbirth or puerperium).

If a screening test is conducted at the same visit, the five-digit code would be matched up to the appropriate screening code. For instance, an NST (fetal nonstress test) conducted due to the patients hypertension would read as: 59025/642.03 (fetal nonstress test; benign essential hypertension complicating pregnancy). Likewise, each subsequent E/M visit and procedure(s) would be listed with the service or procedural code first, followed by the diagnostic code on the same line.

Some insurers will want you to file extra visits individually, says Callaway-Stradley. Others want you to submit the global code only with a -22 modifier (unusual procedural services) to explain the extra time spent with the patient. If the option is to use the modifier, Callaway-Stradley suggests submitting the global ob claim with a detailed cover letter and complete notes of each visit and test conducted. Then they (the carrier) can go through your notes and decide whether to pay for the extra visits, says Callaway-Stradley. Since the computer only reads the first diagnosis code, it is important to have the other information in the file in case you have to go back and ask for an appeal. You want all the information to be included in that original claim. That way, even if the insurer didnt read it the first time around, it doesnt appear as though you were trying to add anything after the fact.

In Woods experience, using the five-digit code rather than the V code as the primary one has worked best. Use what is wrong with the patient as your primary code, says Wood. She is pregnant and has hypertension. This is the problem; this is specifically why you are ordering an NST. You want the insurer to know what warranted the testuse the diagnostic codes to explain your reasoning."