Primary Care Coding Alert

Remember the differences between urge and stress incontinence.

Primary care practitioners (PCPs) are often a patient’s first stop for healthcare concerns, and many would rather stick with their PCP than have to see several different specialists. As coders in primary care practices, this means you need to have a solid understanding of a variety of conditions and age groups.

When it comes to post-menopausal patients, hormonal changes can lead to a variety of conditions that you may not be familiar with. Follow us as we walk though some common ones.

Condition refresh: Menopause is the normal physiologic cessation of menstruation that occurs as a woman ages, because the ovaries stop producing estrogen and the reproductive system gradually shuts down. This process, which has an average age of onset at 50.5 years, usually takes approximately one year to complete, but it may last anywhere from six months to more than five years.

Understand Osteoporosis Versus Osteopenia

Due largely to the decrease in estrogen, bone loss is a common concern for post-menopausal women and their doctors. In fact, bone density screenings, or bone mass measurements (BMMs), are an important part of your provider’s care plan because “women of postmenopausal age, women who may be estrogen deficient and at risk for osteoporosis… should be screened for bone density,” says Dianne Nakvosas, ACS-RAD, Senior Medical Coder at Compubill, Inc., Tinley Park, Illinois. This statement is also supported by the US Preventive Services Task Force, which recommends screenings to prevent fractures (www. uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening).

Osteoporosis (M81.0, Age-related osteoporosis without current pathological fracture) is essentially a bone disease caused by dropping estrogen levels in postmenopausal women. Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, and wrist. When reporting M81.0 or any of the other codes in the M81 (Osteoporosis without current pathological fracture) family, you should use additional codes to identify (if applicable) major osseous defect (M89.7-) or personal history of (healed) osteoporosis fracture, (Z87.310).

Osteopenia is a condition characterized by a lower-than-normal bone mineral density. Your ICD-10 options are the codes included in M85.8- (Other specified disorders of bone density and structure). The correct code is determined by the location (i.e., shoulder, hand, upper arm, forearm, thigh, lower leg, ankle/foot, or other). While osteopenia can be a risk factor or precursor for developing osteoporosis, not all patients who have osteopenia develop osteoporosis. Sometimes, the doctor will write something like “pre-osteoporosis” in the notes for this reason.

Note: The practitioner most likely will order a dual energy X-ray absorptiometry to code the condition, which may be written out as “DEXA” or “DXA” and will code to one of the following:

• 77080 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine))
• 77081 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel))
• 77085 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine), including vertebral fracture assessment)

Look Out for Atrophic Vaginitis

Another common issue for women experiencing a drop in estrogen is vaginal thinning, shrinking, and decreased lubrication. For example, let’s say the practitioner sees a 55-year-old woman who is complaining of vaginal dryness, itching, and discomfort during sexual intercourse. Her last menstrual period was about a year ago. Upon examination, and considering her age and symptoms, the doctor diagnoses atrophic vaginitis. You should report this with N95.2 (Postmenopausal atrophic vaginitis).

Note: Generally, the lack of estrogen during and following menopause causes this condition, and in this instance, the physician took a variety of things into account. However, additional causes for atrophic vaginitis include decreased estrogen due to decreased ovarian function after radiation or chemotherapy, oophorectomy, postpartum changes, and immune disorders. Always check with the provider if you suspect additional diagnosis codes might be required.

The documentation will need to include details that lead up to this diagnosis. The physician will diagnose this condition via a pelvic exam, but they may order lab tests to confirm menopause and rule out other conditions that might mimic it, so be sure to not prematurely report a diagnosis based on suspicion only. With ICD-10, you are bound by Guideline IV.H, which tells you not to document a condition “as ‘probable.’ ‘suspected.’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty.” Instead, you code the condition(s) to the highest degree of certainty for that encounter, such as symptoms, signs, abnormal test results, or other reason for the visit.

In other words, “you should never report rule-out diagnoses in the outpatient setting,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group. But the documentation should include it if it supports any tests or further workups.

E/M alert: The potential for a serious problem based on uncertainty is not reason enough to bump an encounter up a level in medical decision making (MDM). However, those details having to do with the physician’s suspicions (if any) should still be included in the documentation and may influence MDM associated with the encounter to a degree that will warrant a higher level. For instance, if the PCP’s uncertainty necessitates ordering labs or other tests to confirm or definitively rule out a diagnosis, that may increase the amount and/or complexity of data to be reviewed and analyzed, which, in turn, may increase the level of MDM and level of (evaluation and management) E/M service, depending on the other elements of MDM.

Be On The Lookout for Incontinence

Estrogen helps keep the lining of the bladder and urethra healthy. Without enough estrogen, these tissues may deteriorate, which can lead to incontinence. Weight gain is also common during this time of life, which can put pressure on the bladder and lead to incontinence. General muscle weakness due to childbirth and simple age is also a factor affecting this demographic.

To code incontinence correctly, you need to be able to distinguish between two different types of the condition

Urge incontinence is common in post-menopausal women, and “urge” is the distinguishing descriptor to look for in the clinician’s documentation. This describes the patient’s sudden urge to urinate, making it challenging at times for the patient to make it to a bathroom in time. It can come on quickly and happen during the day or night, and it is caused by the bladder contracting. It’s not triggered by a specific external event, such as sneezing or laughing. To report urge incontinence, you’ll submit N39.41 (Urge incontinence).

Stress incontinence, on the other hand, describes a patient’s inability to retain urine when a stressor occurs. Those stress triggers might include laughing, sneezing, jumping, coughing, or lifting heavy items. To report this diagnosis, use the following code N39.3 (Stress incontinence (female) (male)). If the patient has a mix of urge and stress incontinence, you will report that with N39.46 (Mixed incontinence).