Ob-Gyn Coding Alert

Your ob-gyn’s documentation may, in some instances, need to become more specific.

If you’ve peeked at the roughly 750 ICD-10-CM additions, deletions, and revisions coming your way October 1 of this year, then you may find yourself overwhelmed. Allow our experts to narrow down what your ob-gyn practices needs to start learning now.

Remember: Proper diagnosis coding demonstrates medical necessity for your physician’s work. Plus, Medicare quality reporting programs rely on appropriate diagnosis coding to evaluate appropriate procedures — so missing the boat now could impact your bottom line later.

“It is important to remain in compliance with ICD-10-CM coding and quality measures,” affirms Michele Midkiff, CPC-I, RCC, a coding consultant in Mountain View, CA.

1. Maternal Code for Abnormalities of Fetal Heart Rate

Some pregnant patients require greater maternal care because of the fetal heart rate problems, and ICD-10-CM has now brought you a second code to report this, but during the antepartum period rather than during labor. “Just like the existing code O76 (Abnormality in fetal heart rate and rhythm complicating labor and delivery), you now can report things likes a non-reassuring fetal heart rate or fetal tachycardia or bradycardia with this new code,” says Melanie Witt, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

The main code you should know is O36.83- (Maternal care for abnormalities of the fetal heart or rhythm …). This code requires sixth and seventh characters.

Sixth character: You will need to choose your sixth character based on trimester. In other words, you will add a “1” for first trimester, “2” for second trimester, “3” for third trimester, or “9” for unspecified trimester.

Seventh  character: For your seventh character, you will specify the fetus. Your options are “0” for a singleton pregnancy or when the number of fetuses is now known, “1” forfetus 1, “2” for fetus 2, “3” for fetus 3, “4” for fetus 4, “5” for fetus 5, or “9” for other fetus.

Example: Suppose you have a second trimester pregnant patient requiring maternal care for fetus 2. You will report O36.8322 (Maternal care for abnormalities of the fetal heart rate or rhythm, second trimester, fetus 2).

2. Tackle These New Tubal, Ovarian Pregnancy Coding Options

Deletion: As of October 1, 2017, you will be deleting the following codes:

• O00.10 (Tubal pregnancy without intrauterine pregnancy),
• O00.11 (Tubal pregnancy with intrauterine pregnancy),
• O00.20 (Ovarian pregnancy without intrauterine pregnancy), and
• O00.21 (Ovarian pregnancy with intrauterine pregnancy).

Replacement: Instead, you’ll need to choose from the following code structure:

• O00.101 (Right tubal pregnancy without intrauterine pregnancy),
• O00.102 (Left tubal pregnancy without intrauterine pregnancy),
• O00.109 (Unspecified tubal pregnancy without intrauterine pregnancy).

Codes O00.111-O00.119, O00.201-O00.209, and O00.211-O00.219 also follow this pattern of their sixth character (1, 2, 9) specifying right, left, and unspecified.

Takeaway: The ob-gyn will now need to document where anatomically the tubal or ovarian pregnancy is occurring — the right or left side. You also have the unspecified option, but you should always code to the highest level of specificity.

Example: Your ob-gyn treats a patient with a left ovarian pregnancy with an intrauterine pregnancy. You’ll report this condition after October 1 with O00.212 (Left ovarian pregnancy with intrauterine pregnancy).

3. Learn These New Antenatal Screening Codes

Deletion: As of October 1, you can say goodbye to Z36 (Encounter for antenatal screening of mother).

Replacement: Instead, you’ll say hello to a slew of more specific antenatal screening codes, as follows:

• Z36.0 (Encounter for antenatal screening for chromosomal anomalies)
• Z36.1 (... for raised alphafetoprotein level)
• Z36.2 (Encounter for other antenatal screening follow-up)
• Z36.3 (Encounter for antenatal screening for malformations)
• Z36.4 (… for fetal growth retardation)
• Z36.5 (… for isoimmunization)
• Z36.81 (… for hydrops fetalis)
• Z36.82 (… for nuchal translucency)
• Z36.83 (… for congenital cardiac abnormalities)
• Z36.84 (… for fetal lung maturity)
• Z36.85 (… for Streptococcus B)
• Z36.86 (… for cervical length)
• Z36.87 (… for uncertain dates)
• Z36.88 (… for fetal macrosomia)
• Z36.89 (Encounter for other specified antenatal screening)
• Z36.8A (Encounter for antenatal screening for other genetic defects)
• Z36.9 (Encounter for antenatal screening, unspecified).

Takeaway: You’ll no longer rely on that catchall code Z36. You will need to emphasize why the patient underwent this encounter for antenatal screening.

Example: Suppose a pregnant patient learns from the quad screening that her baby may have some chromosomal abnormalities as the AFP values are elevated, and she wants to discuss this with her physician. After October 1, 2017, you would report an office visit (99211-99215, Office or other outpatient visit…) and attach the new code Z36.1.

4. Expand Your Unspecified Lump in Breast Coding Options

Deletion: As of October 1, 2017, you will have to delete code N63 (Unspecified lump in breast).

Replacement: When your ob-gyn performs a breast procedure, from fine needle aspiration (such as 10022,  Fine needle aspiration; with imaging guidance) to biopsy (such as 19101, Biopsy of breast; open, incisional), you’ll need to have more info on the anatomic site.

The latest update to the code set adds new codes with fourth and fifth-digit specificity based on laterality and breast quadrant, as follows:

• N63.0 (Unspecified lump in unspecified breast)
• N63.1- (Unspecified lump in right breast) and N63.2- (Unspecified lump in left breast) with a fifth character specifying 0 (unspecified quadrant), 1 (upper outer quadrant), 2 (upper inner quadrant), 3 (lower outer quadrant), and 4 (lower inner quadrant).
• N63.3- (Unspecified lump in axillary tail) with a fifth character representing 1 (of the right breast) and 2 (of the left breast).
• N63.4- (Unspecified lump in breast, subareolar) with the fifth character representing 1 (right) and 2 (left).

The index also revises the entry for Breast Nodule to “Breast Nodule (see also Lump, breast) N63.0.”

Tip: “You should be waiting for the pathology report and using the final diagnosis to report your surgeon’s diagnostic and therapeutic breast procedures, so your practice should not be using these ‘unspecified lump’ codes very often,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebraska.

5. Don’t Miss These Miscellaneous Additions

As usual, you also have a mish mash of other revised and new diagnoses to learn that may affect your ob-gyn practice. However, you should not overlook them, as doing so could result in a denial.

Encounters: Check out how Z31.5 (Encounter for genetic counseling) will become Z31.5 (Encounter for procreative genetic counseling) and Z40.02 (Encounter for prophylactic removal of ovary) will become Z40.02 (Encounter for prophylactic removal of ovary[s]) (emphasis added).

You’ll also add Z40.03 (Encounter for prophylactic removal of fallopian tube[s]) and Z71.83 (Encounter for nonprocreative genetic counseling) to your coding cache.

These encounter code revisions and additions may clear up some coding confusion you might have endured.

BMI: You’ve also got a subtle change in your body mass index (BMI) to note. Code Z68.1 (Body mass index [BMI] 19 or less, adult) will become Z68.1 (Body mass index [BMI] 19.9 or less, adult). This means that after October 1, 2017, for patients with a BMI of 19.5, you should report Z68.1 and not jump to the next code up.

Counseling: Additionally, you have a new counseling code to learn: Z71.82 (Exercise counseling).

HRT: You need to note this hormone replacement therapy revision. Code Z79.890 (Hormone replacement therapy [postmenopausal]) will become Z79.890 (Hormone replacement therapy) with no “postmenopausal” in brackets. This allows you to report this code for any patient requiring this therapy.

Stay tuned to Ob-gyn Coding Alert for more ICD-10-CM 2018 updates and impacts. Plus, you can access the file yourself at www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html. You should use these codes October 1, 2017 through September 30, 2018. To help with the transition, General Equivalence Mappings (GEMs) will be available sometime in August 2017.