Ob-Gyn Coding Alert

Ob/gyn coders: There are rules for correct coding and optimal reimbursement that you can and should follow, regardless of carrier or patient circumstances.

At a recent pediatric and ob/gyn coding and compliance conference sponsored by The Coding Institute, experts offered the following pointers for successfully coding women's health services:

Tip #1: Document height, weight and blood pressure. In doing so, the physician documents the constitutional system as part of the examination. Or the review of the information can be used to document the portion of history that entails the review of systems (ROS), according to Philip Eskew Jr., MD, medical director of infant and women's services at St. Vincent's Hospital in Indianapolis.

A review of the patient's height represents a review of the musculoskeletal system, blood pressure indicates a review of the cardiovascular system, and weight a review of the constitutional system, Eskew says. Not only do these vital signs help the physician pinpoint possible problems, but they can be taken by the nurse and recorded in the chart for the physician to review. The physician can discuss any unusual weight gain or loss, changes in blood pressure, or loss of height (associated with osteoporosis) with the patient during the face-to-face encounter, he adds.

Tip #2: Make the physician choose the E/M and ICD-9 codes for the visit. Coders shouldn't be stuck second-guessing their physicians as to what care was rendered and what diagnoses determined the need for the service, according to Eskew. With E/M visits, a coder or practice staff member could easily downcode or upcode a visit, resulting in lost revenue or skewed statistics of higher-level visits.

An incorrect diagnosis code can result in denial of payment for a number of reasons. The carrier might not pay for the indicated diagnosis, or treatment might not match the carrier's list of linked diagnoses, Eskew says. Rather than determining the physician's intent based on chart notes, practice and coding managers should work with their physicians to instill the importance of doing their own coding. The alternative is lost revenue and possibly even an audit or allegations of fraud, he warns.

Coders and physicians should not use the "R" word when seeing a patient on a consultative basis, advises Harry L. Stuber, MD, an independent gynecologist based in Cookeville, Tenn. In other words, the chart note should not read, "Patient A was referred by Dr. B for evaluation and management of ... ", Stuber explains. Instead, the physician might indicate that "Dr. B has sent patient A for consultation regarding the evaluation and management of... " The term "referral" implies that a transfer of care has taken place and the referring physician is essentially handing the patient's problem to the ob/gyn for further treatment, Stuber advises. For a true referral, the patient's initial visit would be coded as a new patient E/M service (e.g., 99203, Evaluation and management of a new patient ...), assuming the physician or a fellow ob/gyn physician working in the same practice had not seen the patient within the past three years, Stuber says.

Payers reimburse consultations at a higher rate than new patient visits, Stuber says. So if the criteria for a consultation are met, the appropriate consultation code should be billed (e.g., 99243, Office consultation for a new or established patient ) even if a transfer of care takes place following the consultation.

If a patient is sent from another physician with a complaint of pelvic pain (625.9, Unspecified symptom associated with female genital organs), and the gynecologist diagnoses an ovarian cyst, he or she may schedule an ultrasound and surgery to excise the cyst, Stuber says. Technically, a transfer of care for that specific problem of the cyst has taken place. But at the initial consultation with the patient, the gynecologist should still send a written note back to the primary care physician acknowledging the request for consultation and discussing the findings and recommendations for treatment.

Tip #4: Don't confuse modifiers -52 (Reduced services) and -53 (Discontinued procedure). Modifier -52 is used when a procedure performed actually comprises fewer of the components defined by the code being reported, or the physician work is less than would be normally expected for the code billed, Stuber says. The modifier is used when no CPT code accurately describes the work done; rather, an existing code is modified to show that less work was performed.

Modifier -53 is used when the procedure is stopped in the midst of surgery due to patient circumstances discovered at the time of surgery that make it impossible to complete.

In the ob/gyn setting, for example, an endometrial biopsy (58100*, Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]) that cannot be completed because of cervical stenosis is appended with -52, Stuber says. If the patient is under anesthesia, has an arrhythmia, and the procedure is cancelled, use -53. Modifier -53 was created for procedures that were discontinued due to a problem, not altered and completed by, for example, another route, Stuber counsels.

Tip # 5: Use the primary diagnoses for diagnostic tests. For Medicare patient diagnostic coding, CMS has a new wrinkle in the rules, Stuber says. Effective Jan. 1, 2002, physicians should code to the diagnosis, rather than the symptom when billing diagnostic tests. Stuber illustrates this point with the example of a suspected ovarian cyst. The patient reports to the office with pelvic pain and tenderness, and the gynecologist performs an ultrasound. Based on CMS' former method for coding, the physician would have coded pelvic pain (625.9) as the reason for ordering the ultrasound. Now, CMS wants the physician to use the actual diagnosis of ovarian cyst (if one is found) as the reason for the test. If no cyst is found, then 625.9 remains the code to submit when billing for the test. But if a cyst is found, then the appropriate code (e.g., 620.0, Follicular cyst of ovary) is used when submitting charges for the ultrasound. If the physician is ordering a test that will be performed elsewhere (and if the physician will not be billing for that test), the reason for ordering the test may still be indicated on the referral slip. The billing radiologist or pathologist, however, needs to follow the new guidelines, he notes.

Tip #6: Obtain an ABN (advance beneficiary notice) from Medicare patients. "Obtaining an ABN can mean the difference between being able to collect on services Medicare deems 'not medically necessary' or not," says Wanda Brown, CPC, president of ProActive Coding Service in Jacksonville, Fla.

A typical ABN would include items that Medicare may or may not pay for, Brown says. The patient's signature is a guarantee of payment from him if Medicare denies the claim.

An ABN does not need to include items that Medicare never pays for, only those items that are covered under certain circumstances or are subject to carrier discretion, Brown explains. The -GA modifier (Waiver of liability statement on file) lets Medicare know that the physician has reason to believe that the service might not be covered but that the patient has agreed to pay for it in that case. It allows the physician to balance bill the patient for the Medicare allowable (or the limiting charge).

For example, Brown says, Medicare covers pelvic and breast exams every two years for the low-risk patient. If the physician is unsure whether this is the year Medicare will deny the claim, the patient can sign the ABN, and the physician would append modifier -GA to G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). If Medicare denies the service, the physician can now collect the payment from the patient, she says.

Update: Most coders will have noticed that Medicare added a new modifier -GZ (Item or service expected to be denied as not reasonable and necessary) in 2002 to signify essentially "ABN not on file." CMS has indicated that the physician may use this modifier when the patient is either unable or unwilling to sign an ABN at the time of a service that is expected to be denied for medical necessity. CMS has cautioned, however, that this does not mean you will be able to collect from the patient in this circumstance. If no ABN is signed and on file, the carrier may instruct the patient not to pay the provider without extenuating documentation.

Tip #7: Learn which CPT codes are bilateral codes and which are unilateral. Unless CPT says otherwise, all surgical codes are unilateral, Brown says. So if a unilateral procedure is performed on both ovaries, it can be billed twice using modifier -50 for bilateral procedure.

However, if CPT states that a procedure is bilateral, or unilateral OR bilateral, then it is only billable once, Brown says. For example, 56640 (Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy) is a unilateral procedure. Code 56637 (... with bilateral inguinofemoral lymphadenectomy) is a bilateral procedure.

Tip # 8: Track the number of antepartum visits for each patient. Rather than trying to calculate the number of visits after the fact, keep track of antepartum visits as the patient's pregnancy progresses, advises Melanie Witt, RN, CPC, MA, an independent coding educator from Fredericksburg, Va.

Doing so allows the practice to determine which visits you can bill outside the global package, Witt says. In tracking each visit, the physician should make a note on the chart as to what the visit was for. This is especially important in problem E/M visits (e.g., 99212, Evaluation and management of an established patient), which can be billed outside of global but only if they are documented as such, she notes.

Tip # 9: Itemize procedures for two primary surgeons. When billing for surgeries with two primary surgeons, start by itemizing all the procedures listed by both, then "throw out" those normally bundled with a major gynecological surgery, such as exploratory laparotomy, Witt says. Next, see if any CPT code or codes describe more than one of the component procedures. Bill that code or codes with modifier -62 (Two surgeons) for each surgeon. Any additional procedures not captured above can then be billed separately by the surgeon who performed them, she says.

If an ob/gyn performs a total abdominal hysterectomy with bilateral salpingo-oophorectomy and finds cancer, he or she will probably call the gynecological oncologist to the operating room, Witt says. The oncologist performs an omentectomy with pelvic and limited para-aortic lymphadenectomy. A diagnostic cystoscopy is also performed. Code 58951 (Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy) describes all the procedures except the cystoscopy. Both surgeons would bill for 58951-62 (Two surgeons), and the surgeon who performed the cystoscopy (52000, Cystourethroscopy [separate procedure]) would bill for it with modifier -51(Multiple procedures) (or in some cases -59 if this procedure is bundled with the other billed procedure) appended, she advises.

Tip #10: "Incident to" coding applies only to Medicare. This elementary rule can make a big difference in how practices use their nonphysician practitioners (NPPs), Witt says. Medicare's incident to rule requires that a physician be present in the office suite when an NPP is treating patients. The rule also stipulates that NPPs cannot treat new patients.

However, private payers have their own rules for NPPs, Witt cautions. Many allow NPPs to treat new patients, and some even allow a physician assistant (PA) to be the supervising provider in the office when other NPPs are treating patients. Knowing each carrier's rules for NPP billing can prevent repayment of claims after an audit if the rules are not followed, she notes.