Ob-Gyn Coding Alert

"The Health Care Financing Administration (HCFA) recently announced new and revised ICD-9 codes for 2001. With several changes affecting ob/gyns, practices are wise to start reviewing their patient encounter forms to keep them up-to-date. Although the changes are effective Oct. 1, 2000, many payers will wait until Jan. 1, 2001, before processing claims using the new codes. Check with your payers about when they will start accepting the new codes.

The changes help to clarify language that in some cases was a little cloudy. The new codes also bring more definitive diagnosis options to the physician, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C.

Code Revisions and Clarifications

Numeric ICD-9 codes represent infectious and parasitic diseases. V codes are for factors other than disease or injury that influence health (i.e., pregnancy).

564.1 The language of this code for irritable colon has changed. The new nomenclature reads irritable bowel syndrome, the most frequently used term for this condition.

791.9 This change clears up some confusion by referencing pyuria (urine that contains pus) to a single code, 791.9. Previously, the alphabetic index referenced this condition to 599.0 (urinary tract infection, site not specified) (under the heading of pus) and code 791.9 (other nonspecific findings on examination of urine) (under the heading of pyuria).

646.8x This code is to be used in place of 655.8x (other known or suspected fetal abnormality, not elsewhere classified) when diagnosing the condition uterine size-date discrepancy. The code to report this service will be 646.8x (other specified complications of pregnancy). ICD-9 also has added the descriptor uterine size-date discrepancy to the code in the tabular index.

656.3x In the current ICD-9 book, the term fetal distress, NOS is listed among the conditions excluded from 656.3x. If the physician indicated the term fetal distress without mention of fetal metabolic acidemia, 656.8 (other specified fetal and placental problems) would have been the correct code. This was an error that has been corrected. If a physician indicates a diagnosis of fetal distress or fetal metabolic acidemia, 656.3x (fetal distress) should be reported.

663.8x Code 663.5x (the fifth digit denotes the current episode of care), vasa previa, included velamentous insertion of the umbilical cord as an inclusion term in the tabular index. The American College of Obstetricians and Gynecologists (ACOG) pointed out that this was not accurate. For 2001, the reference to this condition is deleted from 663.5 and added to 663.8x (other umbilical cord complications) because it more accurately describes the conditions diagnostic category.

V13.7 An excludes note was added to V13.7 (personal history of perinatal problems). This code no longer will be used if the perinatal problem dealt with low birth weight. Instead, V21.30-V21.35 (see new codes below) will be used to indicate a low birth weight status.

V25.8 Code V25.8 (other specified contraceptive management) now expressly excludes a sperm count following sterilization reversal or for fertility testing.

V26.3 Code V26.3 has been revised to include genetic counseling and genetic testing other than fertility testing. Fertility testing should be reported using the new code V26.21 (see below).

V49 (series) The V49 (problems with limbs and other problems) category has been redefined as other conditions influencing health status even though it still includes codes that describe problems with limbs. In addition, the category has been expanded to include postmenopausal status (see below).

V58.4 Because of the addition of V26.22 (see below), code V58.4 (other aftercare following surgery) cannot be reported when the aftercare takes place following sterilization reversal surgery.

New Codes

ICD-9 also added 21 new codes that will assist ob/gyns who struggle with medical justification for care, tests and procedures. The new codes provide sharper diagnostic tools for ob/gyns. They pinpoint specific disorders and will help to prove medical necessity to skeptical carriers, says Melanie Witt, RN, CPC, MA, former program manager for ACOGs department of coding and nomenclature and an independent coding educator.

645 (series) Code 645 (prolonged pregnancy) now allows physicians to report both prolonged pregnancy (beyond 42 weeks of gestation) and post-term pregnancy when the pregnancy is longer than 40 weeks, but less than 42 weeks, 1 day. The two new codes are 645.1x (post-term pregnancy) and 645.2x (prolonged pregnancy). Both codes require a fifth digit of 0 (unspecified as to episode of care or not applicable), 1 (delivered, with or without mention of antepartum condition) or 3 (antepartum condition or complication). The new code for post-term pregnancy, 645.1, was proposed by ACOG.

781.9x Medical justification for bone density studies for osteoporosis has been difficult because the only code available was very nonspecific (781.9). Code 781.9 has now been expanded to include three new codes: 781.91 (loss of height), 781.92 (abnormal posture) and 781.99 (other symptoms involving nervous and musculoskeletal systems). When a physician suspects but has not confirmed osteoporosis, 781.91 should be used.

783.2x Code 783.2 has been expanded to two new codes, one to report loss of weight and the other to report a person who is abnormally underweight. These codes are 783.21 (loss of weight) and 783.22 (underweight).

V26.2x (series) The V26.2 (procreative management investigation and testing) category has been expanded to include codes specific to fertility testing (including fallopian insufflation and sperm count for fertility testing) and aftercare following sterilization reversal (also including fallopian insufflation and sperm testing following the reversal). ICD-9 also added a specific note to indicate that fertility testing excludes genetic counseling and testing (V26.3). The new codes are V26.21 (fertility testing), V26.22 (aftercare following sterilization reversal) and V26.29 (other investigation and testing). The New York Health Information Management Association (NYHIMA) requested the code for post-sterilization reversal visits.

V45.77 A code has been added for those circumstances when the absence of a genital organ affects treatment of the patient at the time of the encounter. The new code, V45.77 (acquired absence of genital organs), is one of five new codes under V45.7 and was created so the physician can differentiate between surgical absence and congenital absence. Often, this code could be reported when reconstruction procedures are being considered.

V49.81 This new code, for postmenopausal status (age-related) (natural), recommended by NYHIMA, represents one of the most significant changes to ICD-9 from an ob/gyn perspective. The code can be used to report estrogen deficiency in the postmenopausal patient who is not taking hormones (which would be V07.4, postmenopausal hormone replacement therapy) and who is not having postmenopausal symptoms (627.2, menopausal or female climacteric states). Witt explains that V49.81 should be a useful code to justify osteoporosis screening in women who are at risk for developing the disease due to low levels of estrogen. To reinforce correct usage of this code, a note has been added to 256.2 (postablative ovarian failure), 256.3 (other ovarian failure) and category 627 (menopausal and postmenopausal disorders) to indicate that these codes exclude asymptomatic age-related postmenopausal status.

According to Amy Blum from the National Center for Health Statistics ICD-9 coordination and maintenance staff, the code would be used only when the cause of the estrogen deficiency is age-related, not because the patient had surgery that put her into premature menopause. If the patient had menopausal symptoms due to having her uterus and ovaries removed, the correct code would be 627.4 (states associated with artificial menopause). If you are trying to report that she had gone into menopause at an early age, the correct code would be 256.3 (other ovarian failure) because she would have an endocrine disease causing the problem rather than normal aging.

It is not yet clear, however, if Medicare will accept this code as justification for ordering a screening bone density study, says Witt. Be sure to check with your carrier before using this code for this justification.

V58.83 For encounters that involve therapeutic drug monitoring, this code has been added. It would be used for monitoring prescribed drugs, not for drug testing for medicolegal purposes (V70.4). For example, if the patient is on a drug for hypertension that requires a check-up every six months due to possible side-effects, this would be the code to use.

V67.01 Reporting encounters dealing with vaginal Pap smears always has been problematic, but code V67.01 (follow-up vaginal Pap smear) can now be reported for a follow-up examination (and collection of the vaginal Pap smear specimen) of a patient who has had a hysterectomy for a malignant condition. The physician also should use the new V45.77 to indicate there is an acquired absence of the uterus and a third code to indicate a personal history of cancer (V10.40-V10.44).

V71.81 This code was added to report observation for abuse and neglect. The code cannot be used when the abuse is confirmed, only when abuse or neglect is suspected but the patient has no complaints. If after further examination the physician finds no problem, this is the only code that may explain the reason for the encounter. If there has been confirmed abuse, report 995.80-995.85 for adult abuse, or 995.50-995.59 for child abuse.

V76.4 (series) Code V76.4 (special screening for malignant neoplasms, other sites) now includes two additional sites: V76.46 (ovary) and V76.47 (vagina). Code V76.47 is an important addition because it allows reporting of a screening vaginal Pap smear collected from a patient whose uterus was removed for a nonmalignant condition (such as prolapse). Report V45.77 in addition to V76.47 to identify the acquired absence of the uterus.

V76.5x (series) Other codes have been added under V76 to allow more accurate reporting of colon cancer screening. These include V76.50 (intestine, unspecified), V76.51 (colon) and V76.52 (small intestine). Note that V76.51 excludes screening for rectal cancer, which is reported as V76.41. Also, it is not yet clear whether Medicare will accept V76.51 as a valid diagnosis for colorectal screening via the hemoccult test, so be sure to check with the carrier before using this code.

V77.91 For ob/gyns who also do primary care and frequently order cholesterol levels on their patients at the time of the annual exam, a code has been added to indicate this. It is V77.91 (screening for lipoid disorders) and includes screening for hypercholesterolemia and hyperlipidemia as well as the cholesterol levels.

V82.81 Code V82.81 (special screening for osteoporosis) will require the addition of a second code to indicate the patients postmenopausal status. The potential second codes are V07.4 if the patient is taking hormones or V49.81 if she is naturally postmenopausal (i.e., low estrogen levels). Once again, its best to check with your Medicare carrier to see if they will accept this new code for bone density studies.

The new ICD-9 additions, says Witt, are encouraging proof that the ICD-9 coding committee is willing to work proactively with ACOG and other involved parties to develop more specific codes. The result will mean that more accurate, explicit claims are submitted to carriers, which ideally, will mean fewer denials."