Ob-Gyn Coding Alert

One of these new V codes will demonstrate a higher risk of pregnancy complications.

Although five months seems like plenty of time to accustom yourself to new ICD-9 codes, don't be caught unaware when October 1 strikes. You've still got forty-four new ob-gyn codes through which to wade.

Plus, you need to prepare your ob-gyns to include more information in their notes. "Some of these codes are going to be tough to get the detailed information to use them, as the doctors aren't usually very specific about these conditions," says Jan Rasmussen, PCS, CPC, ACSOB, ACS-GI, owner and consultant of Professional Coding Solutions in Holcombe, Wis.

Simplify what's new by highlighting the following five areas that may have you changing your multiple gestation, infertility, and regular office visit claims -- for good.

1. New Placenta, Amniotic Sac V Codes Support More Monitoring

When a patient carrying twins has only one placenta with two amniotic sacs, you currently have no way to reflect the higher risk of complications and the rationale behind the ob-gyn's differing treatment plan. Because category 651 (Multiple gestation) has fifth digits to represent the episode of care, there was no way to expand these codes.

New way: The ICD-9-CM Coordination and Maintenance Committee created a new V category, as proposed by the Society for Maternal-Fetal Medicine (SMFM) with the endorsement by the American Congress of Obstetricians and Gynecologists (ACOG). The new codes are:

V91.00 -- Twin gestation, unspecified number of placenta, unspecified number of amniotic sacs

V91.01 -- Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)

V91.02 -- Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)

V91.03 -- Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)

V91.09 -- Twin gestation, unable to determine number of placenta and number of amniotic sacs.

Bonus: You'll find similar V codes for triplet gestations (V91.10-V91.19), quadruplet gestations (V91.20-29), and other unspecified multiple gestations (V91.91-V91.99).

Example: The ob-gyn delivers twins vaginally with two placentae and two amniotic sacs. You would report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; Multiple procedures) for the second. To support these CPT codes, you'd link each to 651.01 (Twin pregnancy; delivered) and add a secondary diagnoses of V91.03 and the outcome code V27.2 (Twins, both liveborn).

Benefit: Using the new V code allows for better data collection regarding the types of twin pregnancy, and in some cases, when reported during the antepartum period, may help establish medical need for interventions or closer monitoring that cannot be adequately captured using the V23 high risk codes.

2. Cheer for Personal History of Dysplasia Code

Every four to six months following treatment, your ob-gyn may see patients who have had vaginal or vulvar dysplasia to verify that there has been no recurrence. This history may be the sole reason for the encounter, and currently you have no way to reflect this. Also, "personal history codes are nice to support testing," Rasmussen notes.

Starting this October, you will have new codes for personal history of vaginal and vulvar dysplasia:

V13.23 -- Personal history of vaginal dysplasia

V13.24 -- Personal history of vulvar dysplasia.

Also: You have one more personal history code: V13.62 (Personal history of other [corrected] congenital malformations of genitourinary system).

Example: A patient presents for a follow-up to a bicornuate uterus, which the ob-gyn corrected surgically six months ago. Because the patient is no longer in the postoperative period and she is not presenting for aftercare, new code V13.62 will adequately explain the reason for the visit (99211-99215, Office or other outpatient visit for an established patient ...).

If this visit takes place prior to October 1, you can report only V67.09 (Follow-up examination; following other surgery), which is not as specific.

3. Add Five More Uterine Anomalies to Your Arsenal

A developing female reproductive tract undergoes a process involving a complex series of events including cellular differentiation, migration, fusion, and canalization. If this process has an aberration, the patient will have congenital anomalies. Müllerian anomalies include all congenital anomalies of the uterus, cervix and vagina. They do not include congenital anomalies of the ovaries, which have a separate embryologic origin.

The American Society of Reproductive Medicine (ASRM) identified seven types of uterine anomalies: agenesis, unicornuate, didelphus, bicornuate, septate, arcuate, and DES related anomalies. Of these, only didelphus and DES related anomalies have unique ICD-9 codes: 752.2 and 760.76, respectively. For the other anomalies, you have no specific diagnosis recourse.

Good news: As of Oct. 1, you'll be able to differentiate between these different types, and payers will translate these codes into specific gynecologic and obstetric implications and management. They are:

752.31 -- Agenesis of uterus

752.32 -- Hypoplasia of uterus

752.33 -- Unicornuate uterus

752.34 -- Bicornuate uterus

752.35 -- Septate uterus

752.36 -- Arcuate uterus

752.39 - Other anomalies of uterus.

Note: Your ob-gyn will find these uterine anomalies difficult to determine, because women with some of these conditions are asymptomatic. The patient won't know she has an anomaly until she has a problem with conception or maintenance of a pregnancy. Depending on the anomaly, she may experience increased rates of first and second trimester spontaneous abortion, preterm labor, preterm delivery, and malpresentation.

Vaginal/cervical: You won't see many vaginal or cervical anomalies, but that doesn't mean you shouldn't take note of these upcoming changes. A patient may present to your practice with obstructed menstrual flow. She may have amenorrhea or cycle pelvic pain. She may have problems conceiving or with a pregnancy.

You already have codes for imperforate hymen (752.42), and embryonic cyst of cervix, vagina, and external female genitalia

(752.41). But Oct. 1 will bring more options:

752.43 -- Cervical agenesis

752.44 -- Cervical duplication

752.45 -- Vaginal agenesis

752.46 -- Transverse vaginal septum

752.47 -- Longitudinal vaginal septum.

4. Focus on These Fecal Incontinence Symptoms

Fecal incontinence can present as problematic symptoms, such as fecal smearing, fecal urgency, and incomplete defecation. Remember: Incomplete defecation is distinct from constipation and fecal impaction. Rectum and anal sphincter problems (including rectoceles) can cause these problems, but currently, you don't have a way to specify these symptoms.

When Oct. 1 rolls around, you'll no longer be able to report 787.6 (Incontinence of feces). ICD-9 will delete it. Instead,you'll use one of the following new codes:

787.60 -- Full incontinence of feces

787.61 -- Incomplete defecation

787.62 -- Fecal smearing

787.63 -- Fecal urgency.

5. Break Down New Body Mass Index Codes

Lastly, "they've expanded the body mass index (BMI) codes to demonstrate higher BMIs with five new codes," notes Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, with CRN Healthcare Solutions in Tinton Falls, NJ.

"That's scary," Rasmussen says. "That says we're, as a nation,getting bigger and bigger."

What will happen: Your current V85.4 (Body Mass Index 40 and over, adult) code will expand to the fifth digit level, so that you have body mass index (BMI) codes specifying 40.00 to 49.9, and a BMI of 50 and over. Examine the definitions of the following new codes:

V85.41 -- Body Mass Index 40.0-44.9, adult

V85.42 -- Body Mass Index 45.0-49.9, adult

V85.43 -- Body Mass Index 50.0-59.9, adult

V85.44 -- Body Mass Index 60.0-69.9, adult

V85.45 -- Body Mass Index 70 and over, adult.

Benefit: "BMI has become an important health tool, and those codes will also provide more data," says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting & Coding Education, LLC.