Ob-Gyn Coding Alert

Once a diagnostic code is established for the treatment of a patient, is it etched in stone or is there a point at which a code can be changed or refined to a more specific diagnosis? What happens when a screening exam results in the diagnosis of a problem? Can that screening code be changed to a diagnostic one? Three key factors affect the choice of codesintent of the visit, change of complaint and documentation of the need for additional tests.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., explains some of the subtleties of coding for screening vs. diagnosis, using the following cases as examples.

A patient appears with complaint of abdominal pain. This examination is diagnostic in nature, as the ob/gyn is trying to identify the cause of the complaint. An ultrasound is scheduled for the following week, at which time fibroids are found.

A patient presents for her annual screening Pap smear and pelvic examination. During the course of the exam, she complains of bleeding between periods. The physician suspects the presence of fibroids, and schedules the patient to return for an ultrasound the following week.

These two case scenarios present different but related coding problems and, as Callaway-Stradley says, are a tricky issue. What you are getting into is just how far you can push the diagnosis code to get the highest reimbursement without crossing the line. There is so much confusion with this issue because many coders think that you can never change the diagnostic code from one problem to another. But you can, and its financially constructive for you to do so. Essentially, abdominal pain doesnt pay. Fibroids do. So if the physician is able to diagnose fibroids at the time of the initial examination, use fibroids as your primary code rather than the presenting complaint.

Intent of the Visit Is an Important Distinction

The distinction, explains Callaway-Stradley, is whether the patient appeared with a specific complaint. ICD-9 guidelines state that you can use the diagnosis code that is the most definitive diagnosis as your primary code if you started with some sign or symptom in the patient, she says. But you cant change the code if you started off screening a patient and the screening test results come back two days later showing a problem.

It may sound like a question of semantics, but it is an important distinction. If the patient presented for the collection of a screening Pap specimen, you cannot change the primary code for that visit, no matter what the results are, says Callaway-Stradley. What I have found in my professional experience working with practices is that some practices want to change codes when they shouldnt, and others are afraid to change the codes that they are allowed to change.

The question is one of preventative vs. problem-oriented care. With Medicare rules, says Callaway-Stradley, its fairly clear cutyou have to pick one code or the other, diagnostic or screening. Many commercial carriers will say you can submit both a problem-oriented (diagnostic) and a preventive (screening) claim, but in reality, they will only reimburse for one. As long as patient history supports you doing so, you are ahead to pick the diagnostic, or problem-focused, code.

Change of Complaint Can Mean Change of Code

Occasionally, a patient may have her annual screening scheduled, but in the weeks leading up to her appointment, develop problems such as abdominal cramping (789.0-9, abdominal pain [with a fifth digit to specify location]) or bleeding between periods (626.6, metrorrhagia; irregular intermenstrual bleeding). In this case, it is incumbent upon the patient to mention these problems when she reports for her exam.

But as Callaway-Stradley reminds, Patients dont always know what to tell their doctors, or what is a normal condition for them to be experiencing. What you really need in the physicians notes is a clear statement of how the problem has overtaken the issue of preventive medicine. If continuing with the already-scheduled Pap smear is the best way to reach a diagnosis, the ob/gyn needs to support that in his or her notes. Essentially, the doctor is going to have to defend that the Pap smear was a diagnostic one and not a screening Pap (ICD-9 code V76.2, special screening for malignant neoplasms; cervix) as was originally scheduled. And as we know, says Callaway-Stradley, Pap smears seldom work that way. So using bleeding between periods as the complaint, the coding sequence would read 626.6/V76.2.

Curt Udell, CPAR, CPC, president of Emphysys Inc., a medical coding consulting company in Cumming, Ga., supports Callaway-Stradleys view that whenever possible, use the most specific diagnostic code possible. But he cautions not to jump to any coding conclusions.

When you begin coding the complaint of abdominal pain, assuming you will be treating the patient over the course of more than one visit, your diagnostic code needs to support the tests you will be running on the patient. You want to use the most symptom-specific code that you can. In other words, you suspect fibroids, and through a series of tests you will determine whether the patient has fibroids. Default to the sign or symptom in your coding, says Udell, but dont use the fibroid diagnosis unless it has been determined thats what it is. So your initial code for this patient is 789.0-789.9 (abdominal pain [with a fifth digit to specify location]).

After tests come back, or the patient returns for an ultrasound and the physician can determine the presence of fibroids, code the next visit using fibroids as the diagnosis (218.0-218.9, uterine leiomyoma [fibroid]). On that visit 218.0218.9 would be listed as the primary code, with any additional test codes, like an ultrasound (76700, echography, abdominal, B-scan and/or real time with image documentation; complete), listed after it. What youre saying by using this coding sequence, says Udell, is that you strongly suspect the presence of fibroids and you are conducting an ultrasound to verify your suspicion. The sign or symptom dictates the diagnostic code of fibroids.

Document the Need for Additional Tests

Documentation at the first visit will also establish the need for future visits and tests. You are using the first visit, says Udell, to determine whether the ultrasound is necessary. By documenting the chief complaint of abdominal pain, you set out the plan for what tests need to be performed to make an assessment or diagnosis in the second or other subsequent visits.

The patient may present with a complaint of abdominal pain and have an ultrasound on the same day. This is unusual though, says Udell, because a lot of practices cannot work in time for diagnostic testing during a normal office visit. Many doctors prefer that the patient return for a second visit when they can do more diagnostic procedures, as well as have more interview time.

If the office visit and the ultrasound or other testing occur on the same day, Udell strongly recommends two separate interpretations and procedural notes on two separate forms, meaning you are establishing that two distinctly different services occurred. In your first note, you are listing the patients complaint of abdominal pain (789.0, abdominal pain) as the primary code on the exam note, says Udell. Then, if you do an ultrasound because you suspect fibroids, on a separate note, list fibroids as your primary and diagnostic code, and the ultrasound second. You can do this by having a separate page attached to the evaluation and management (E/M) note (for the office visit). It really equals two notes in the eyes of most auditors.