Ob-Gyn Coding Alert

Question: The patient came in for clean catch urine (87086).-Dx was back pain (724.2).-Medicare denied as "not medically necessary." (No other symptom documented in chart).-No advance beneficiary notice (ABN) form was signed.-Outside lab is billing patient.-I called the lab and they said the explanation of benefits (EOB) stated patient responsibility.-Of course, the patient wants me to change the diagnosis on the requisition.-What should I do?

Iowa Subscriber

Answer: You can't make a diagnosis appear that your ob-gyn does not document.-Back pain would not be even close to a reason for doing a urine culture. The ob-gyn may have been thinking of some kind of bladder or kidney infection, but without an additional urinary tract symptom, you are not going to get reimbursed by most companies.-In other words, per-the payer, your claim does not establish medical necessity.-

Action: At this point, you can appeal on behalf of the patient and let the MD know that he will have to write to the payer with his rationale as to why he ordered the culture.

The answers for Reader Questions and You Be the Coder provided by Melanie Witt, RN, CPC-OBGYN, MA, an ob-gyn coding expert based in Guadalupita, N.M.