Ob-Gyn Coding Alert

Tests with different names don't always mean different codes

Tackle your most common ob-gyn tests to make sure you-re coding them correctly and reining in the appropriate payment for these in-office tests. Mark the Most Common: Urinalysis Your ob-gyn will likely report a urinalysis to check for pregnancy more than any other test. You-ll report it using 81025 (Urine pregnancy test, by visual color comparison methods). The results are immediate, so your ob-gyn has no need to send the specimen to an outside laboratory.

Note: You won't include most tests in your E/M fee. You can report lab tests in addition to your E/M code (99201-99205 for new patients, 99211-99215 for established patients).

Important: The Clinical Laboratory Improvement Amendments (CLIA) deemed the urine pregnancy test as a -waived- test, meaning this test is so simple that little risk of error exists. Caution: You still need a certificate to perform a waived test. The law requires that all laboratories have a certificate and obtain a CLIA number. So when you report the urine pregnancy test, you would also apply modifier QW (CLIA-waived test) to 81025. Be sure to include your CLIA number on the claim form.

Want to see if your in-house tests are CLIA-waived? For a free list of current CLIA-waived tests, e-mail suzannel@eliresearch.com. Code the Following 3 Tests Using 87210 Don't be fooled--just because some in-house tests have different names doesn't mean you should report a different code for each.

Wet mount: When the ob-gyn does a wet mount, he swabs the vagina, puts the sample on a glass microscope, and mixes it with a salt solution, says Barbara White, billing supervisor of Women's Total Care of East Texas in Jacksonville. He examines the prepared slide under the microscope and checks for bacteria, yeast cells, trichomoniasis organisms (trichomonads), white blood cells indicating an infection, or clue cells that indicate bacterial vaginosis. -This involves a smear specimen for infectious agents,- says Terri R. Viar, CPC-A, an ob-gyn coder at Women's Care PA in Shawnee Mission, Kan.

KOH slide: This lab test mixes the vaginal sample with potassium hydroxide (the KOH) in addition to the salt solution. The KOH destroys bacteria and cells from the vagina, leaving yeast hyphae and spores (if present) that indicate a yeast infection.

Whiff test: The whiff test is another part of the KOH test procedure. The physician will smell the sample that was prepared with the potassium hydroxide to see if a strong fishy odor is present. If so, the odor suggests bacterial vaginosis. -If the ob-gyn smells a fishy -amine- odor, most likely they have bacterial vaginosis,- says Mary Lou Martin, CMM, CPC, a healthcare consultant at Skoda, Minotti & Co. Healthcare Services in Cleveland. (Note: See section below [...]