Ob-Gyn Coding Alert

Action: Isolating key phrases will capture the correct code every time Your colposcopy coding choices are numerous, and so are the chances to pick the wrong code, which could cost you money. Take this challenge and see if you pick the proper CPT and ICD-9 code in each instance. Clue: Zoom in on what your ob-gyn did in addition to the colposcope -- biopsy, endocervical curettage, or loop electrocautery excision procedure (LEEP)? Highlight 3 Key Phrases in This Note Procedure: Your ob-gyn's documentation states: "I cleansed the cervix, including upper/adjacent vagina, several times with 3 percent acetic acid. After adequate time for the acetic acid effect, I examined the cervix and vaginal fornices with a colposcope at several magnifications. I looked at the transformation zone completely. "I noted an abnormality consisting of leukoplakia, mosaicism, punctuation, or atypical vessels during the exam. At noon, the patient had abnormal acetowhite areas extending into the endocervical canal, and I took a cervical biopsy. I treated the biopsy site with Monsel's solution or silver nitrate for hemostasis." What CPT and ICD-9 codes should you report in this situation? Solution: First, you should isolate the important information. According to Peggy Stilley, CPC-OGS, ACS-OB, clinic manager at OU Physicians in Tulsa, Okla., critical phrases are: - including upper/adjacent vagina - transformation zone completely - cervical biopsy at noon. CPT: Narrow down your coding options. From the first phrase, you know to look at the codes that "describe the inspection of the cervix with upper/adjacent vagina," Stilley says. Therefore, your options are 57454 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix and endocervical curettage), 57455 (... with biopsy[s] of the cervix), 57456 (... with endocervical curettage), or 57461 (- with loop electrode conization of the cervix). "Your decision depends on the additional procedure the ob-gyn does, whether it is a biopsy, endocervical curettage (ECC), LEEP excision, and so on," Stilley says. In this case, the ob-gyn performed only a biopsy, hence the third phrase: "cervical biopsy at noon." You will report 57455 for this procedure. Note: The difference between a biopsy and a LEEP cone is that in a biopsy the ob-gyn takes only the transformation zone, but with a LEEP, she takes the transformation zone plus the endocervix. ICD-9: Although you need more information to choose your ICD-9 appropriately (because you must always base it on the physician's documentation), here are the likely codes: 795.01-795.05, 795.08-795.09 (Abnormal Papanicolaou smear of cervix and cervical HPV -). Keep Similarities With First Procedure in Mind Procedure: Your ob-gyn's documentation states: "I cleansed the cervix, including upper/adjacent vagina, several times with 3 percent acetic acid. After adequate time for the acetic acid effect, I examined the [...]