Ob-Gyn Coding Alert

When the physician writes pelvic inflammatory disease (PID) in the diagnosis section of the patient chart should you automatically choose the unspecific code 614.9 for inflammatory disease of the pelvic organs and tissues (PID)? Not without careful consideration, says Linda Dominguez, RN-C, a womens health nurse practitioner from Albuquerque, NM. Something might be called PID based on what the findings suggest, but PID cant be definitively diagnosed without doing a laparoscopy. Thats why there isnt a specific code for PID. A further understanding of this disease and how the codes for Inflammatory Disease of the Female can assist the ob/gyn coder in correct coding and avoiding rejections.

Dos and Donts of Diagnosis Coding for PID

The section in the ICD-9 that covers inflammatory diseases of the female pelvic organs is 614-616. It contains a number of very specific codes that includes inflammatory diseases of the ovary, fallopian tubes, pelvic cellular tissue and peritoneum. Mixed in among the specific codes are some nonspecific codes such as 614.9 (unspecified inflammatory disease of female pelvic organs). The specific codes not only identify the inflammatory diagnosis, they are specific as to exact location. In addition, the codes are further divided into acute or chronic. Acute codes should be used when the onset has been sudden and severe. Chronic codes should be used when coding a problem that has been persistent and lingering.

Whether the codes in this section are specific or nonspecific, it is important to note that all of them are used to report a confirmed inflammatory process. The only time we use these specific codes, says Lisa A. Lorence, medical billing specialist with the ob/gyn section of the Toledo Clinic, is when the patient has come back from surgery, or the doctor has specifically indicated a confirmed diagnosis. There are no codes in this section for suspected or rule-out pelvic inflammatory processes.

I wouldnt use the nonspecific codes, Lorence says. Instead, she says that if she saw a diagnosis of just PID, without any indication in the chart of how it was confirmed, she would go ask the caregiver questions to help code more specifically. Betty Ruppersberger, billing manager for Center for Womens Health in Langhorne, PA agrees. I usually ask the physician, she adds. Both Lorence and Ruppersberger echoed one of the cardinal rules of diagnosis coding, that one should always code the symptoms if you do not have a confirmation of the disease. Start with what the patient came to the office for, explains Lorence, and then use the PID code (614.9) as a secondary diagnosis. Ruppersberger says one of the most common symptoms is abdominal or pelvic pain, so she would code the pain as the primary diagnosis and then follow with the rule out PID as a secondary diagnosis.

Mary McClure, CPC a coding specialist from Tenet Physician Services in Ft. Lauderdale, FL says, We have used the unspecified code for PID without problems, but if the physician is not sure, we would code the symptoms. If McClure has a problem with the codes being rejected, she also says she checks with the carrier to see what they wanted, and then revises and resubmits the claims.

When a diagnosis of inflammatory disease of female pelvic organs is made, the ICD-9-CM asks that additional codes be used to identify the organism such as Staphylococcus (041.1) or Streptococcus (041.0). The codes 614-616 are not to be used for inflammation disease associated with:

endometritis (615.0-615.9)

major infections following surgery (670)

inflammation complicating
- abortion (634-638 with .0, 639.0)
- ectopic or molar pregnancy (639.0)
- pregnancy or labor (646.6).

What Is PID?

Pelvic inflammatory disease is the general term used to describe an infection from the vagina or cervix to the uterus including the fallopian tubes, and broad ligaments. According to Contraceptive Technology (Robert A. Hatcher, M.D. et al, Ardent Media , Inc. 1997), PID is responsible for 180,000 hospitalizations every year in the United States with more than 1 million episodes occurring annually. One in 7 American women of reproductive age reports having received treatment for PID. Almost any bacteria may cause the disease. Its complex to diagnose, says Dominguez, the nurse practitioner from NM. The agents of infection are N. gonorrhea, C. trachomatis, anaerobic bacteria, facultative gram-negative rods (such as E. coli), Mycoplasma hominis, as well as other agents. The most common clinical agents are N. gonorrhea and C. trachomatis.

Presenting symptoms may include pain and tenderness in the lower abdomen, cervix, uterus, and adnexa, fever, chills, vaginal discharge and elevated white blood cells and erythrocyte sedimentation rate. PID is often seen in women who have had multiple sex partners, a history of PID, the recent insertion of an IUD, or women who are in the first 5 to 10 days of their menstrual cycle.

According to Dominguez, a rule out diagnosis is often made on the symptoms and history alone, but a definitive diagnosis can only be made during a laparoscopy or laparotomy. You cant call it PID until its actually confirmed, she says. The treatment of PID usually involves a regime of antibiotics.

Diagnosis Codes for Pelvic Inflammation 614.0 Acute salpingitis and oophoritis 614.1 Chronic salpingitis and oophoritis 614.2 Salpingitis and oophoritis not specified 614.3 Acute parametritis and cellulitis 614.4 Chronic or unspecified parametritis and pelvic cellulitis 614.5 Acute or unspecified pelvic peritonitis, female 614.7 Other chronic pelvic peritonitis, female (nonspecific) 614.8 Other specified inflammatory disease of female pelvic organs and tissues (nonspecific) 614.9 Unspecified inflammatory disease of female pelvic organs 615.0 Inflammatory disease of uterus, acute 615.1 Inflammatory disease of uterus, chronic 615.9 Unspecified inflammatory disease of uterus 616.0 Cervicitis and endocervicitis 616.10 Vaginitis and vulvovaginitis, unspecified