Ob-Gyn Coding Alert

Question: The patient saw the OB nurse for her first visit for this pregnancy and gives the nurse her LMP. Before patient sees a provider, a maternal fetal medicine provider sends her for an ultrasound. The nurse gives patient EDD of 2/7/16 based on LMP. The MFM provider performs the ultrasound and changes the EDD to 2/14/16. I know we are using ICD-10 now, but this visit took place in September. My MFM provider wants to use a diagnosis of 649.63, but my coder wants to use V28.89. Which is correct?  Most of our insurance companies do not cover the diagnosis V28.89, so the charges will drop to the patient and my physician will be very upset. What should I do?

Pennsylvania Subscriber

Answer: First and foremost, you cannot fix a coverage issue with coding. That said, you would need to apply the diagnosis code that represents the documented reason it was ordered.  Having an MFM provider do the ultrasound seems to imply there was a special issue that required this level of specialty, but your question has not addressed this.

If the nurse ordered the ultrasound because there was a uterine-size date disagreement based on her exam, then 649.63 (Uterine size date discrepancy, antepartum condition or complication) would be the appropriate code.

However, if the ultrasound was ordered as a routine screening ultrasound for dating, a V28.89 or even V22.0 or V22.1 would be more appropriate.  Remember that the rules in ICD-9 (and ICD-10 as well) state that a diagnostic test order for screening is coded with that screening diagnosis as primary, but the provider is free to add the finding as a secondary diagnosis.  If the payer covers a screening ultrasound, then they either have to accept a V28 code or a V22.0 or V22.1 code for doing the screening.  You cannot change the reason for the order just because you get a “result” that might be construed as a problem. 

Also, be sure that the initial documentation clearly identifies the reason for the ultrasound and that that information is correctly and clearly communicated to the provider who will be performing the test.

ICD-10: All antenatal screening tests are now coded using a single code Z36 (Encounter for antenatal screening of mother). Code V22.0 is reported now as Z34.0_ and V22.1 is Z34.8-.  ICD-9 code 649.63 is reported as O26.84-(Uterine size-date discrepancy complicating pregnancy). Note all of these codes except Z36 require a final digit that represents the trimester.