Ob-Gyn Coding Alert

Question: I have a pregnant patient who underwent a vaginitis screen/wet prep, because she has had increased discharge. How would I bill this, so it wouldn't be included in the global? 

South Carolina

Answer: You should bill 87210 (Smear, primary source with interpretation; wet mount for infectious agents [e.g., saline, India ink, KOH preps]) for the wet mount, but whether you can bill an E/M code (such as 99213, Office or other outpatient visit ...) for the evaluation that is separate from routine care is very much dependent on what your ob-gyn documented.  

For instance, was this a patient complaint, or was it simply found on an examination? If found by the provider, you probably don't have a separate E/M, and you should bill 87210 only. 

If the ob-gyn documented that the discharge was incidental to pregnancy (or not complicating it), you can report a non-OB complication code if you have a separate significant E/M as part of the record (only count those items that are related to the discharge, not any of the antepartum visit in selecting the level of service).

The diagnosis code that you use for both a potential office visit outside of global care and the performance of the wet prep (87210) will depend on the result of the wet smear. Also, this will depend on whether the physician documented the discharge as being incidental to pregnancy or a complication of pregnancy. If positive for vaginitis and the physician has documented that this condition is incidental to pregnancy, your choice will be: 616.10 (Vaginitis and vulvovaginitis unspecified) and V22.2 (Pregnancy state, incidental).

If instead, the provider is silent about this condition's impact on the pregnancy, you must assume it is complicating pregnancy per ICD-9 rules, and your code will be 646.63 (Antepartum infections of genitourinary tract).

If no vaginitis was found, you code for the discharge complaint. In that case, if unrelated to pregnancy, the diagnosis could be 623.5 (Leukorrhea, not specified as infective). If related to pregnancy, then the source of the discharge must be identified more specifically in order to assign a diagnosis code.

ICD-10: When your diagnosis system changes, you will report the following equivalents:

• Code 616.10 becomes N76.0 (Acute vaginitis) or N76.1 (Subacute or chronic vaginitis)
• Code V22.0 becomes Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester)
• Code 646.63 expands to 8 possible codes:
  
• O23.591 (Infection of other part of genital tract in pregnancy, first trimester)
• O23.592 (...., 2nd trimester)
• O23.593 (...., 3rd trimester)
• O23.599 (...., unspecified trimester)
• O23.90 (Unspecified genitourinary tract infection in pregnancy, unspecified trimester)
• O23.91 (...., 1st trimester)
• O23.92 (...., 2nd trimester)
• O23.93 (...., 3rd trimester)
  
• Code 623.5 becomes N89.8 (Other specified noninflammatory disorders of vagina)