Supplement-Expert Answers to Your Most Vexing Ob-Gyn Coding Questions
Ectopic Pregnancy
Question: I am looking for a CPT code for a packaged procedure for an ectopic pregnancy treatment. The physician is treating the patient in the office with methotrexate intramuscular to dissolve the ectopic growth. Is there one procedure code that includes the office visit and the injection?
Cheryl Kuehne, CPC
Multicare Associates, Blaine, Minn.
Answer: A general rule with most third-party carriers is that if a therapeutic injection is given at the time of a visit, the administration (90782, therapeutic or diagnostic injection; subcutaneous or intramuscular) of the medication is bundled into the visit code. In this scenario, the provider would bill for the evaluation and management (E/M) visit (99201-99215) and the HCPCS code for the medication (J9260, methotrexate sodium, 50 mg). Note that the drug methotrexate is a chemotherapeutic agent and, as such, some payers may allow the physician to bill 96400 (chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia) in addition to the E/M service, even without a cancer diagnosis, but check with your payer before trying this method.
If the patient is receiving just the injection and there is not a separately identifiable E/M service rendered and documented, the administration code 90782 (or 96400 when allowed) is billed in addition to the HCPCS code for the medication.
- Answered by Emily Hill, PA-C, president of Hill & Associates, a coding and compliance consulting firm based in Wilmington, NC.
Established Patient or Well Visit?
Question: A patient came to our office for her annual exam. She was on birth control pills and hormone replacement therapy and had no new complaints. Her prescription for birth control pills and hormones was renewed for the year. Is this an established patient visit or a well visit?
Jenie Graham, RRA, CCS
Ob & Gyn Specialists, PC, Davenport, Iowa
Answer: When coding for any service, ask, "What is the reason for the patient’s visit today?" Patients on birth control pills or hormone replacement therapy are usually given these medications for prophylactic or preventive reasons. Therefore, for annual checkups (established patient), you would use the preventive medicine codes representing the patient’s age - commonly 99394-99397 (periodic preventative medicine reevaluation and management of an individual including a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, established patient) for gynecological patients.
Also note that part of the description of the service is "risk factor reduction interventions." This is where birth control and hormone replacement therapy come into play. Remember that the intent of age-based codes clarify that not all examinations fall under the same type of history, exam, and other contributory factors for each age group. The ICD-9 code must correctly identify the reason for the visit as well. For instance, include V07.4 (postmenopausal hormone replacement therapy) if the patient presents for a routine gynecological exam and renewed prescription of hormone replacement therapy. A patient having problems with her medication - for instance, a menopausal patient comes to the office complaining of hot flashes while taking 0.5 mg of estradiol daily - would constitute a problem-oriented evaluation and management service (99211-99215). To indicate medical necessity, assign 627.2 (menopausal or female climacteric states).
- Answered by Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va.
E/M Visit With OB Global
Question: We charge an evaluation and management (E/M) visit for the first obstetric visit and then bill the global fee at delivery. Is it ever acceptable to bill separately for each subsequent OB visit and then bill the global at delivery? I am aware of the antepartum codes, and we use these only for OB patients who leave our practice. Many times, we will see our OB patients for more than the 13 visits usually considered part of global.
Arizona Subscriber
Answer: According to guidelines published by the American College of Obstetricians and Gynecologists, the first visit included in the global OB package is the one in which the OB record is initiated, although you may want to check with individual insurers for their particular guidelines. If a patient is seen more than the typical number of times (13 antepartum visits) for other than a normal pregnancy (the patient is diabetic, for example), the total number of antepartum visits can be added together and any beyond the normal 13 can be billed at the end of the pregnancy.
The physician will need to document these extra visits very carefully so the coder will know exactly how many extra visits took place, the reason(s) for the visits, and the level of E/M service supported by the documentation.
- Answered by Melanie Witt, RN, CPC, MA, an independent coding educator.
Transvaginal Ultrasound
Question: How can I code a transvaginal ultrasound of the ovaries to follow follicles in a gonadotropin-stimulated cycle? Generally, I perform one ultrasound when I see the patient initially and code 76856, then code 76857 for the follow-up transvaginal scans used to measure follicles. The corresponding diagnosis is usually an infertility code like 628.9 (infertility, female, of unspecified origin).
Maryland Subscriber
Answer: There are two options for billing an initial ultrasound: 76830 (echography, transvaginal) or 76856 (echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete). The only difference between the two is that the procedure described by 76830 uses a vaginal transducer, while 76856 is performed with an abdominal transducer. According to the American College of Obstetricians and Gynecologists’ Ob/Gyn Coding Manual: Components of Correct Procedural Coding, the imaging for both procedures involves a study of the "uterus, tubes, ovaries and pelvic structures, as indicated." Therefore, the approach should determine which code to use.
Note: The Medicare fee schedule assigns the same number of RVUs for both 76830 and 76856 (2.62 RVUs in 2000, and 2.61 RVUs in 2001), so there is no financial advantage to using one code over the other.
For the follow-up to check for follicles, 76857 (echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [e.g., for follicles]) clearly describes the procedure performed and may be reported. In this case, there is no need to differentiate between a transvaginal and abdominal approach.
- Answered by Melanie Witt, RN, CPC, MA, an independent coding educator.
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