Ob-Gyn Coding Alert

“Polyhydramnios” is a key term when it comes to CPT^®, ICD-10 selection.

When a patient undergoes an amniocentesis procedure, you need to be prepared to code these claims — with confidence. Before you encounter potentially confusing terms like “polyhydramnios” and “twin-twin transfusion syndrome (TTS),” take a look at this amnio note and break down your coding steps.

Check Out This Note

The ob-gyn sees a patient with a rapidly increasing uterine size at 22 weeks gestation.

Limited ultrasound scanning reveals the presence of a twin gestation. One twin is small for gestational age and has oligohydramnios. The other twin is appropriate for gestational age but has severe polyhydramnios.

The ob-gyn makes a diagnosis of a twin-twin transfusion syndrome and counsels the patient as to the available therapies. The patient elects amniotic fluid reduction. The ob-gyn explains the risks and benefits of the procedure.

He performs real-time ultrasound scanning to identify the sac with increased amniotic fluid. The physician drapes and preps the area. Then he identifies the needle insertion site. Under real-time ultrasound guidance, he inserts a 22-gauge needle into the amniotic sac.

He then attaches the needle to a drainage system. Using continuous ultrasonic guidance, he removes the fluid until he sees a normal amount of fluid on the ultrasound.

The physician remains in constant communication with the ultrasound operator regarding the status of both fetuses and the fluid level; this continual monitoring of the needle location is required to avoid injury to the fetus or placenta since the removal of fluid alters the uterine shape.

Once the patient has a normal fluid level, the physician removes the needle.

Pull Out Key Terms and Codes

The key term to look for is “polyhydramnios,” experts say. This term indicates the physician needs to reduce the amniotic fluid.

Diagnosis codes: As this procedure is being performed at 22 weeks gestation (second trimester), you should submit O40.2xx1 (Polyhydramnios, second trimester, fetus 1) or O40.2xx2 (… fetus 2). The final digit relates to which fetus has he polyhydramnios so make sure the documentation supports the code you report. You should report the polyhydramnios because that is what the physician is treating. In addition, you should also report O43.022 (Fetus-to-fetus placental transfusion syndrome, second trimester) to complete the picture.

You could also include O30.0-- category (Twin pregnancy ...). as a secondary diagnosis to add to the story.

Procedure codes: You should report 59001 (Amniocentesis; therapeutic amniotic fluid reduction [includes ultrasound guidance]). Your physician removed large amounts of amniotic fluid for massive polyhydramnios or for twin-twin transfusion syndrome.

Watch out: You should not report 59000 (Amniocentesis; diagnostic). This code represents amniocentesis for diagnostic purposes. You should not report this code for a fluid-reduction procedure.

You would also not report the ultrasound guidance separately because this is clearly included as part of the procedure, as described by 59001. You may, however, report additional ultrasounds (other than the guidance) but only if your ob-gyn addresses problems (unrelated to the amniocentesis) that are affecting the mother or fetus.