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Ob-Gyn Coding Alert

Prepare Yourself for Monumental ICD-9 Changes

Published on Mon Jun 28, 2004

New codes for Pap smear results, endometrial hyperplasia and genital prolapse mean more specificity

With more than 40 new diagnosis codes that will affect ob-gyn practices beginning Oct. 1, now's the time to start familiarizing yourself with them. So dust off your office encounter forms and get ready to make changes.

The biggest and most welcome ICD-9 change is the rework of the Bethesda system codes for abnormal Pap smears, but you'll also see new codes for female genital mutilation and the expansion of the codes for genital prolapse, endometrial hyperplasia and dysplasia. ICD-9 also offers a new obstetric chapter code, several new symptom codes, and V-code changes that will help you identify patients'illness histories.

"All of these codes will help to more clearly define the actual diagnosis," says Judy Troy, an ob-gyn coder with 35 years of experience, and surgical coding coordinator for Capital Women's Care in Silver Spring, Md. "We often have to 'make do'with codes that were not entirely accurate."

More good news: Effective Oct. 1, all payers and providers must accept the new codes. CMS eliminated the grace period, so hopefully you can avoid those "invalid diagnosis" explanation-of-benefits messages and denials.

Get More Specific With Pap Smear Results

"The CDC's National Center for Health Statistics (NCHS) Classification of Diseases committee revised the codes for an abnormal Pap smear (795.0x) in October 2001 to match Bethesda system findings, which more than 90 percent of U.S. laboratories report," says Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va. Just before it implemented this revision, however, the Bethesda Committee revised its terminology so that the new codes were no longer a good match. After many meetings and discussions with the American College of Obstetricians and Gynecologists (ACOG) and others, the NCHS' ICD-9-CM Coordination and Maintenance Committee (ICMC) has effected what should permanently fix Pap smear result coding.

First, the committee removed references to "favor benign" and "favor dysplasia" that the old codes included. Instead, the new codes reflect the hierarchy of conditions beginning with changes to the code's title.

New title: Category 795 is now titled "Other and nonspecific abnormal cytological, histological, immunological and DNAtest findings." Next, the heading for 795.0 will change to allow coding for both an abnormal Pap smear and cervical human papilloma virus (HPV). And finally, new codes will allow you to report findings of high-grade squamous intraepithelial lesion (HGSIL) and a low-grade lesion (LGSIL) and to differentiate between these results and dysplasia. In other words, each result on the pathology report will probably have a specific diagnosis code to describe it, Witt says. The revised code category now also clearly details that you should not use a 795 category diagnosis code to report cervical intraepithelial neoplasia (CIN) or dysplasia pathology results.

The code changes are as follows:

  • 795.00 -- Abnormal glandular Papanicolaou smear of cervix (You will use this code to report atypical endocervical, endometrial or glandular cells that the physician or lab did not otherwise specify. Before the revision, you used this code to report an unspecified abnormal Pap smear result.)
  • 795.01 -- Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US)
  • 795.02 -- Papanicolaou smear of cervix with atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H).

    ASC-H versus ASC-US: Revising 795.01 and 795.02 was crucial because without an accurate ICD-9 code to report ASC-H versus ASC-US, labs had difficulty establishing medical necessity for HPV testing. The American Society for Colposcopy and Cervical Pathology's guidelines recommend HPV testing for ASC-US findings, but not for ASC-H findings, which should proceed to a follow-up colposcopy.

    You'll also use the following new codes quite a bit:

  • 795.03 -- Papanicolaou smear of cervix with low- grade squamous intraepithelial lesion (LGSIL)
  • 795.04 -- Papanicolaou smear of cervix with high- grade squamous intraepithelial lesion (HGSIL) (You would also use 795.04 for a report of cytologic
    evidence of carcinoma.)
  • 795.05 -- Cervical high-risk human papillomavirus (HPV) DNA test positive
  • 795.08 -- Unsatisfactory smear
  • 795.09 -- Other abnormal Papanicolaou smear of cervix and cervical HPV (You will submit this code when a DNA test indicates a low risk for HPV.)

    New unsatisfactory-smear code: Previously, you used 795.09 to report an unsatisfactory smear. But with 795.08, ICD-9 clearly defines which code you should use for an inadequate sample, Witt notes. If you report either 795.05 or 795.09, you should use an additional code to reflect the associated HPV (079.4).

    Leave 795.0x Behind for CIN or Dysplasia

    In addition to the 795.0x changes, ICD-9 offers a second set of revisions that you may use when you report Pap smear results. "When the pathology report uses CIN or dysplasia terminology, your coding choices will come from a different set of codes than those from the 795.0x category," Witt says.

    Code 233.1 (Carcinoma in situ of cervix uteri) references a pathology result of CIN III or severe dysplasia of the cervix or carcinoma in situ of the cervix. In contrast, when the patient has mild to moderate dysplasia or a finding of CIN I or CIN II, you should report one of the expanded dysplasia codes from the 622.1 series. ICD-9 also clarifies that you should report the dysplasia codes as a result of histologic confirmation, while 795.00-795.09 would only involve a cytologic examination.

  • 622.10 -- Dysplasia of cervix, unspecified (You will report this code if the pathology result refers to anaplasia of the cervix, cervical atypism, or cervical dysplasia without further clarification.)
  • 622.11 -- Mild dysplasia of cervix (This code includes a designation of CIN I.)
  • 622.12 -- Moderate dysplasia of cervix (This code includes a designation of CIN II.)

    621.3 Expands for Endometrial Hyperplasia

    In a revision that relates to pathology findings, ICD-9 expands 621.3, which you now use to report endometrial cystic hyperplasia. This condition involves abnormal growth of normal endometrial cells, and if the physician sees atypia in the biopsy sample, the patient is probably at risk for developing uterine cancer. For this reason, ICD-9 will expand the old code into four new codes:

  • 621.30 -- Endometrial hyperplasia, unspecified (You should use this code when the path report does not clarify or qualify the hyperplasia.)
  • 621.31 -- Simple endometrial hyperplasia without atypia
  • 621.32 -- Complex endometrial hyperplasia without atypia
  • 621.33 -- Endometrial hyperplasia with atypia.

    618.0 Develops to Reflect CPT Specificity

    The codes that describe genital prolapse will also receive a major expansion this year. Old code 618.0 (Prolapse of vaginal walls without mention of uterine prolapse) covers a list of conditions ranging from cystocele to vaginal prolapse, but the CPT manual is more specific about the surgery to correct the prolapse. Consequently, ACOG requested that ICD-9 expand the old code to provide additional detail, Witt notes. In addition, because urinary incontinence is commonly associated with genital prolapse, ICMC also added a new code for overflow incontinence. Starting in October, ob-gyns should be as specific as possible regarding the cause of the genital prolapse.

  • 618.00 -- Unspecified prolapse of vaginal walls
  • 618.01 -- Cystocele, midline (or not otherwise specified)
  • 618.02 -- Cystocele, lateral (You will use this code to support performing a paravaginal defect repair.)
  • 618.03 -- Urethrocele
  • 618.04 -- Rectocele or proctocele
  • 618.05 -- Perineocele
  • 618.09 -- Other prolapse of vaginal walls without mention of uterine prolapse (You will submit this code if the physician indicates a cystourethrocele.)
  • 618.81 -- Incompetence or weakening of pubocervical tissue
  • 618.82 -- Incompetence or weakening of rectovaginal tissue
  • 618.83 -- Pelvic muscle wasting (You might use this code for disuse atrophy of the pelvic muscles and anal sphincter.)
  • 618.89 -- Other specified genital prolapse
  • 788.38 -- Overflow incontinence (You will use this new code with any of the prolapse codes [618.0-618.9] as a secondary diagnosis.)

    Look for New FGM Status Category

    ICMC created the new subcategory 629.2, female genital mutilation (FGM) status, because of the potential serious complications associated with genital mutilation practiced in some countries. Type I involves the amputation of part or all of the clitoris; Type II is the excision of both the clitoris and the labia minora; Type III, which is called infibulation, involves removal of the clitoris, amputation of some of the labia minora, and incisions into the labia majora to create a hood of skin that covers the urethra and most of the vagina. You will use these codes as a primary diagnosis for the non-pregnant patient who seeks treatment to correct the mutilation or as a secondary diagnosis when this procedure has been performed on a patient who is pregnant, Witt says.

    The new codes are:

  • 629.20 -- Female genital mutilation status, unspecified
  • 629.21 -- Female genital mutilation Type I status
  • 629.22 -- Female genital mutilation Type II status
  • 629.23 -- Female genital mutilation Type III status.

    Count Cardiovascular Disease Out of 648.6x

    Code 648.6x (Other cardiovascular diseases) specifically excludes peripartum cardiomyopathy, according to the new code definitions. Instead, you will submit 674.5x (Peripartum cardiomyopathy).

    Rethink Your Diabetes Coding

    The new ICD-9 codes also revise the terminology for describing diabetes mellitus, Witt says. The manual will no longer define diabetes as insulin dependent and non-insulin dependent, but rather as type I or type II because the use of insulin is not a determining factor in selecting the appropriate code. The difference between these two is the absence of pancreatic beta cells (type I) or the lack of properly functioning cells (type II). In addition to this change, ICMC adds a new code for long-term (current) use of insulin (V58.67), which you can use as a secondary code.

    Fifth-digit revision: ICD-9 revises the fifth-digit subclassification that you will use with the 250 codes:

  • 0 -- Type II or unspecified type, not stated as uncontrolled
  • 1 -- Type I [juvenile type], not stated as uncontrolled
  • 2 -- Type II or unspecified type, uncontrolled
  • 3 -- Type I [juvenile type], uncontrolled.

    Note that you will report the fifth digits 0 and 2 even if the patient requires insulin. In addition, if the patient requires insulin, you may also report V58.67.

    To view all of the new ICD-9 codes that take effect Oct. 1, go to the CMS Web site at http://www.cms.hhs.gov/medlearn/icd9code.asp.

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