Ob-Gyn Coding Alert

Coders of every medical specialty report difficulty in obtaining adequate, ethical  reimbursement for supplies. For ob/gyn practices, dispensing items such as pessaries, injectable drugs and contraceptive devices often means a low return for the time and money invested. Unfortunately, submitting the correct codes is only half the battle. Practices must often shift more of the financial burden to the patient to reach a break-even point with supplies.

Pessaries
 
A pessary is a silicone or rubber ring worn in the vagina to support a displaced or prolapsed vagina or uterus or to control urinary incontinence. The patient is measured and fitted for the pessary, and it is inserted in an in-office procedure. Code 57160* (fitting and insertion of pessary or other intravaginal support device) is billed to the carrier. The patient returns periodically for pessary cleaning and reinsertion, for which an E/M service is billed.
 
The HCPCS codes for the pessary supply are A4561 (pessary, rubber, any type) and A4562 (pessary, nonrubber, any type). A4562 is the more frequently used code as most physicians now dispense silicone pessaries to their patients because these incur fewer allergic reactions than rubber.
  
There are a number of ways to handle the pessary supply, depending on local-payer policy and the amount of overhead the practice wishes to assume. For non-Medicare patients, the practice can opt to keep a supply of pessaries on hand, which they essentially sell"" to the patient at the time of delivery.
 
Another option for non-Medicare patients is to write a prescription for the pessary" which the patient can have filled at a pharmacy or a medical-supply store. The patient then returns to the practice with the pessary and it is inserted. Practices that follow this method can't charge separately for the follow-up visit when the pessary is inserted. That service is part of the service included in 57160.
 
Medicare patients can also have their pessary prescription filled by an outside source and return to the practice for insertion. The patient then submits the claim directly to the Part B carrier. Note that this is a change of policy effective Jan. 1 2002. A recent CMS program memo instructs that pessaries are to be billed to the local Part B carrier rather than the Durable Medical Equipment Regional Carrier (DMERC) as has been customary until now. This is for claims with service dates on or after Jan. 1 only. Any refiling for an earlier service date would have to be done to the DMERC.

For claims before Jan. 1 2002 the patient submits the claim for the supply directly to the DMERC. However in DMERC Region D (Alaska American Samoa Arizona California Guam Hawaii Idaho Iowa Kansas Mariana Islands Missouri Montana Nebraska Nevada North Dakota Oregon South Dakota Utah Washington and Wyoming) patients are not allowed to submit claims directly to the DMERC. The practice must provide and bill for the supply in-house. If the practice has a DMERC supplier number (obtained from the National Supplier Clearinghouse) it can obtain the pessary from a private medical supplier and submit the bill to the DMERC using either A4561 or A4562.
 
For follow-up care for refitting cleaning and reinsertion the appropriate E/M code is billed.
 
The corresponding ICD-9 Codes for pessary supply and insertion are 618.0 (vaginal prolapse without mention of uterine prolapse) and 618.1 (uterine prolapse without mention of vaginal wall prolapse). Other codes within the 618.x family may apply based on the degree of prolapse.
 
Depo-Provera
 
Billing for injections of Depo-Provera (medroxyprogesterone acetate) particularly for contraceptive purposes is a challenge for most providers. Although the drug has noncontraceptive uses that are more likely to get paid Medicare and most commercial carriers will not pay for it as a means of contraception.
 
The supply code for Depo-Provera depends on the purpose of the injection. If used for contraception it is administered in the office every 12 weeks. The supply code is J1055 (injection medroxyprogesterone acetate for contraceptive use 150 mg). If administered for noncontraceptive purposes such as to control irregular periods the code is J1050 (injection medroxyprogesterone acetate 100 mg). Code 90782 (therapeutic prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) should accompany the claim for the drug supply.
 
Patricia Horvatich office manager for Robyn M. Cook MD a solo practitioner in Kealakekua Hawaii reminds coders that it's important to differentiate between J1055 and J1050 Depo-Provera for contraception versus other treatments. "A lot of people still confuse the two " she says "and the reimbursement is vastly different."
 
Cook's office had always kept the J1055 dose of Depo in stock until recently when the state of Hawaii mandated all health insurers to cover birth control for their subscribers. "When insurances were mandated to pay they told us what we could charge for Depo " Horvatich says. "Some only allowed us to charge $35 when our cost was about $45." When many providers stopped providing Depo forcing patients to pay out-of-pocket from a pharmacy patient complaints to the HMSA (Hawaii Medical Service Association) resulted in an increased allowable. "We can now charge over $45 " Horvatich says. "We still don't make any money but neither do we lose it."
  
As with pessary supply practices often offset the cost of Depo-Provera injections by writing a prescription for the patient and having her fill it and return to the practice for the injection. Because the injections must come at 12-week intervals the patient has enough time between visits to have the prescription filled. If the patient has prescription coverage as part of her insurance benefits and the insurance company does not exclude Depo-Provera from coverage this may be one way to lower the cost of the injection for the patient as well.
 
When the patient returns to the practice for the injection the practice can code either for a low-level E/M visit if an evaluation and management service has been documented or for the therapeutic or diagnostic injection 90782. The J code for medication cannot be used because the office that administered the shot did not supply it.

RhoGAM
 
Injections of Rh-immune globulin (trade name RhoGAM) are administered when a pregnant patient is shown through testing to have Rh incompatibility meaning the mother is Rh-negative and the baby is Rh-positive. Because a single dose of RhoGAM can cost the practice as much as $100 correct supply coding is essential to getting paid for the drug.
 
There are two coding options for RhoGAM supply and which one the practice uses depends strictly on the carrier being billed and what it will accept.
 
For Medicare patients J2790 (injection Rho(D) immune globulin human one dose package) is reported for the drug supply but many non-Medicare carriers will require the HCPCS code as well. Others will require the CPT code for RhoGAM 90384 (Rho [D] immune globulin [RhIG] human full-dose for intramuscular use). Since these are the codes for the drug supply only an additional code is required for the injection.
 
Frustration with paltry payments for RhoGAM like other supplies has forced many practices to require that the patient obtain the drug from a pharmacy. "RhoGAM is problematic " says Horvatich whose office still stocks it. "We take a big loss when we provide RhoGAM but my physician insists upon doing so because she wants to ensure that patients receive this injection at a specific point in their pregnancy. We take a loss of about $50 with each injection."
 
Coders should remember that as of Oct. 1 2002 the Health Insurance Portability and Accountability legislation has mandated that the HCPCS J codes be eliminated and all drugs be billed by their National Drug Code (NDC) number (located on the drug package). This requirement is being argued against by various groups that will be affected but an order to rescind the rule has not been made so the change may still take place says Melanie Witt RN CPC MA an independent coding expert from Fredericksburg Va. "If the change to NDC actually happens CPT will likely delete their codes for drug supply so there will be greater uniformity among carriers when it comes to billing drug supplies " Witt says.
 
In pregnant patients the accompanying ICD-9 code for RhoGAM is 656.13 (rhesus isoimmunization; antepartum condition or complication).

Intra-Uterine Device (IUD)
 
IUDs are fitted for one of two purposes: to prevent pregnancy or to protect from uterine cancer by slowly releasing progesterone locally in the uterus. While reimbursement for the IUD insertion fee (58300 insertion of intrauterine device) is rarely an issue with payers recouping the cost of the IUD is another story.
 
The only current HCPCS code for the IUD is J7300 (intrauterine copper contraceptive). But newer forms of the IUD which are being used more often do not have a specific supply code. These are brand names Progestasert and Mirena IUDs which are noncopper and slowly release hormones over five to 10 years. The closest codes for these are HCPCS J3490 (unclassified drugs) or  CPT 99070 (supplies and materials [except spectacles] provided by the physician over and above those usually included with the office visit or other services rendered [list drugs trays supplies or materials provided]) depending on the requirements of the carrier.
 
These newer products are more expensive than copper IUDs so practices should make sure they are reimbursable by the carrier before dispensing.

With IUD supply in particular preauthorization is a must and coders should request a list of the brand names  from the payer as to which IUDs they will pay for. In many cases practices have the patient pay up-front for the IUD bill the insurance carrier on her behalf and refund the patient what the insurance carrier pays for the device. Because reimbursement is often less than the cost of the IUD practices should advise patients that they are likely to be reimbursed less than they paid. The variance could be as little as a few dollars but perhaps more depending on the carrier.