Get Reimbursed for Nonelective Abortions

Technological advances enable physicians to detect pregnancy in its earliest stages but make coding for spontaneous or missed abortions more complicated. When a patient presents with no prior pregnancy diagnosis, tools such as ultrasound and beta subunit HCG (human chorionic gonadotropin, a pregnancy test that helps determine the stage of pregnancy) confirm pregnancy and enable physicians to determine how far it has progressed. When a patient presents with a pregnancy that has already terminated through nonelective abortion, coding for diagnosis and procedural care can be a challenge, especially for very early-term pregnancies. Often, women who did not seek medical attention for early diagnosis of pregnancy will not identify a delayed menstrual cycle as the loss of a pregnancy and will not be aware that conception occurred. If a pregnancy is diagnosed and terminates, either by spontaneous or induced means, the abortion codes should be used to report the related physician services.

Abortion Terminology


Familiarization with the common types of abortions is the first step to assigning the right ICD-9 and CPT codes.

Complete: The complete expulsion or extraction from its mother of a fetus or embryo; complete expulsion from the uterus of any other product of conception.

Elective: Without medical justification but done in a legal way.

Incomplete: Part of the products of conception have been passed but part (usually the placenta) remains in the uterus.

Induced: Expulsion of the fetus and products of conception brought on purposefully by drugs or mechanical means.

Inevitable: Characterized by rupture of the membranes in the presence of cervical dilation in a pre-viable pregnancy.

Missed: Death of the fetus in utero prior to 22 weeks, with retention of the products of conception.

Septic: An infectious abortion complicated by fever, endometriosis or parametritis.

Spontaneous: An abortion that has not been induced artificially. The term is usually limited to pregnancies of less than 22 weeks gestation.

Editors note: CPT codes for induced abortion (59840-59857) do not distinguish between elective (not medically necessary) or nonelective (medically necessary) abortions. ICD-9 codes 634.x-637.9 describe spontaneous (nonelective) (the fourth digit indicates the contributing complication), legally induced (elective), illegally induced (elective) and unspecified abortion (nonelective).

Spontaneous vs. Missed Abortion

Carla Bryan, CPC, practice manager at Womens Care, a two-physician, one-nurse midwife ob/gyn practice in Hartsville, S.C., says that when determining the right CPT code for a nonelective abortion, the first parameter is whether surgery was required to complete the process. If the patient presents with a spontaneous abortion that is complete (meaning there were no products of conception retained in the uterus), we treat the patient and code it as an evaluation and management (E/M) visit, with no other CPT code, since nothing else was done. Code 634.x (spontaneous abortion) is used for diagnosis. If Bryans physician must evacuate a dead fetus from the uterus through a dilation and curettage (D&C), 632 (missed abortion) is used for the diagnosis, and 59820 (treatment of missed abortion, completed surgically; first trimester) or 59821 (treatment of missed abortion, completed surgically; second trimester) is used for the D&C. By using the code for missed abortion, you indicate that there are retained products of conception that must be surgically removed. A spontaneous abortion code implies that there are no retained products in the uterus and, therefore, no procedural code, she says.

If Its Not Technically a Pregnancy

What procedural codes apply when the patient enters the exam room unaware that she is pregnant, and the diagnosis is something other than a missed abortion? One example is when a physician performs a D&C for a blighted ovum (631, other abnormal product of conception). The code for dilation and curettage, nonobstetrical (58120) doesnt appear to be the answer, but the correct code depends on when or if the blighted ovum and pregnancy were discovered.

The treatment for a blighted ovum, which is a fertilized egg that fails to develop a fetus within it, may be the same as a missed abortion, but only if a pregnancy has been confirmed. Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator, explains the distinctions. A blighted ovum may reabsorb before it is detected, or the patient may exhibit signs of miscarriage. The patient may come in with unexplained vaginal bleeding before she realizes that she may have been pregnant, and a pregnancy test comes back negative. If this is the case, Witt explains, and there is a negative pregnancy test, the proper code for the D&C is 58120 (dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) even if the pathology report indicates a blighted ovum after the fact.

On the other hand, if the patient has been diagnosed as pregnant either prior to or at the same visit, and then begins bleeding, the patient may spontaneously abort (E/M code only) or may require surgery to remove the contents. The blighted ovum may not show up until the pathological reports come back, but because there was a positive pregnancy test, 59812 is used to indicate treatment of incomplete abortion, any trimester, competed surgically.

Although unusual, a patient with a blighted ovum may complain of a missed period only. The physician is likely to order a pregnancy test and do an ultrasound. If the pregnancy test is positive, and the ultrasound reveals a blighted ovum (but no symptoms of abortion, i.e., discharge or vaginal bleeding), the physician will perform a D&C, and 59820 or 59821 would be used along with code 631.

With a blighted ovum, says Witt, you are not inducing abortion because there is no fetus; rather you may be helping along what nature has already started. She adds that, before tests revealed pregnancy at its earliest stages, physicians were more inclined to let nature takes its course and let the body either expel or reabsorb the blighted ovum. But D&Cs or other abortion methods are now employed much more frequently to treat incomplete abortions or induce abortions when a pregnancy is not viable.

Improve Your Hyperplasia Diagnosis Coding Skills Before Oct. 2013 Hits

You won't find one-to-one matches for all your existing ICD-9 codes.

In case a pathology report comes back along with a hyperplasia diagnosis, then there are five possible ICD-9 codes you can report. On the other hand, in ICD-10, you'll only have three choices.

Hyperplasia defined: When hyperplasia takes place, this means the patient has a rise in the number of cells. In the instance of endometrial hyperplasia, this implies that the cells have multiplied in the endometrium, or the inner lining of the uterus.

An endometrial intraepithelial neoplasm is essentially a precancerous lesion in the endometrium that makes the uterine lining more prone to endometroid endometrial adenocarcinoma.

ICD-9-CM Codes: Here are the ICD-9 codes that apply:

621.30 (Endometrial hyperplasia, unspecified)

621.31 (Simple endometrial hyperplasia without atypia)

621.32 (Complex endometrial hyperplasia without atypia)

621.33 (Endometrial hyperplasia with atypia)

621.35 (Endometrial intraepithelial neoplasia [EIN])

ICD-10-CM Codes:

N85.00 (Endometrial hyperplasia, unspecified)

N85.01 (Benign endometrial hyperplasia)

N85.02 (Endometrial intraepithelial neoplasm [EIN])

ICD-10 Change: In the incident of 621.30 and 621.31, you have a one-to-one relationship between your ICD-9 codes and ICD-10 counterparts (N85.00 and N85.01 respectively). Though, ICD-10 rolls 621.32, 621.33, and 621.35 into N85.02.

Documentation: Additional terms for N85.00 contain "hyperplasia (adenomatous) (cystic) (glandular) of endometrium" and "hyperplastic endometritis." A note listed beneath N85.01 includes "endometrial hyperplasia (complex) (simple) excluding atypia. Furthermore, another note under N85.02 is "endometrial hyperplasia with atypia."

Watch out: Assume the provider doubts hyperplasia. He identifies and documents "endometrial thickening" in an ultrasound examination. What diagnosis should you report? JSimply because the provider documents endometrial thickening does not imply that the patient actually has endometrial hyperplasia. A lot of coders make this mistake. You must not code this as hyperplasia as physicians don't always take the thickening of the uterus "abnormal;" in fact; it's simply a monthly "ramp up" for all women. For ICD10, this condition has been referred to R93.8 (Abnormal findings on diagnostic imaging of other specified body structures). You will discover this in the index by searching the term "thickening, endometrium.

Medical Billing and Coding Tips: You should not report hyperplasia until the provider has executed a biopsy, and you have a pathology report that confirms this condition.

ICD-9-CM to ICD-10-CM Transition Update: You have an Excludes1 note in the N85.-- classification, you'll see an Excludes1 note that prevents you from reporting these codes with endometriosis (N80.-), inflammatory diseases of uterus (N71-), noninflammatory disorders of cervix, excluding malposition (N86-N88), polyp of corpus uteri (N84.0), plus uterine prolapse (N81-).

You'll also discover another Excludes1 note under N85.02 preventing you from reporting this particular code with malignant neoplasm of endometrium (with endometrial intraepithelial neoplasia [EIN]) (C54.1).

11040 and Wound Closure: Watch Out for These Conditions to Explain Separate Reporting

Concentrate on the level of wound repair to maximize your reimbursement.

A lot of clinical scenarios do not need dermatologists to carry out debridement as a distinct service from wound closure. Though, recognizing the times when it is essential can help your practice get the full reimbursement it is worthy of. Follow the expert medical billing and coding advice given below and know what CPT codes apply.

In case you're considering reporting debridement distinctly from a wound closure, ensure that your dermatologist's notes clearly document that the wound was contaminated and needed instrumentation and saline or other substances to cleanse and debride the wound. You would require doing a sharp removal to use the debridement code.

Don't miss: In case you report a debridement code, for instance 11040 (Debridement; skin, partial thickness), along with your wound closure CPT codes, append modifier 59 (Distinct procedural service) to the debridement code. This tells the payer that you recognize that debridement is mostly bundled into wound repair, however that clinical circumstances needed the dermatologist to carry out debridement as a separate service.

1. Watch Out for Wound Repair With the Debridement

CPT® specifies that you might also report debridement CPT codes independently of repair CPT codes once the dermatologist gets rid of large amounts of devitalized or contaminated tissue or once the dermatologist carries out debridement without immediate primary repair of a wound.

The dermatologist might clean debris from the wound excluding repairing the wound as it was not deep enough to need repair or the dermatologist delayed the repair because of an extenuating circumstance.

For instance: The dermatologist may not have sufficient time to repair the wound at that particular time, or the patient may present with a more important skin condition that needs medical attention first. In such an instance, you can bill debridement for full, distinct payment minus a wound repair code.

Even though dermatologists most commonly clean a wound instantly before they repair it, you wouldn't report a debridement code separately. Don't miss: The debridement procedure may also require a repair procedure that will affect your medical billing report.

2. Don't Oversee Intermediate Wound Closure for Your Extensive Debridements

In case the dermatologist carries out a simple repair with nominal amounts of debridement, for example, you must only report a simple repair code (12001-12021). In case that same wound requires extensive cleaning or removal of particulate matter, you may, as an alternative, report an intermediate repair code (12031-12057).

Money opportunity: There is an important difference in payment between simple plus intermediate repair CPT codes . Reporting code 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) will reimburse you about $93.60, whereas 12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) may pay $235.20.

Reader Question: Coding for Plaquenil Toxicity Observation

"Question: What is the best way to code for Plaquenil toxicity observation: first, if the patient was referred by the family doctor for a baseline exam prior to the start of treatment; second, if the patient returns six months after the start of treatment to assess ocular changes; and, third, if the patient returns six months later and shows adverse ocular changes?

Marie Stamper, CMM
Ward Eye Center, FL

Answer: Plaquenil (hydroxychloroquine) is a drug used to treat malaria, lupus erythematous, ormost commonlyrheumatoid arthritis. A potential side effect of the drug is ocular change that can affect the patients vision; the patient should be monitored regularly to check for these changes. You should use an evaluation and management services (E/M) office or other outpatient visit code (99201-99215) for the procedure code. For the diagnosis code, use V58.69 (long-term [current] use; of other medications) for the primary diagnosis, and then the diagnosis code which applies to the systemic condition for which the patient is taking Plaquenil (e.g., 714.2, other rheumatoid arthritis with visceral systemic involvement). For the baseline exam done before the patient is taking Plaquenil, use an E/M code with the arthritis as the primary diagnosis. And if you do see adverse changes during a follow-up check for Plaquenil toxicity (in most parts of the country you should still use V58.69 as the primary diagnosis), but use the changes as a secondary diagnosis, as well as the arthritis (or whatever the reason is for the drug to be taken), a few Medicare carriers will want the ocular change as the primary diagnosis and the V58.69 code as secondary. If you are submitting electronically, it is likely best to use the ocular change diagnosis since you can only enter one diagnosis in the field. You can always list the V58.69 code in the note or comment field. In general, you should always list as primary the diagnosis code which most clearly indicates the medical necessity for an ophthalmologist to see the patient.
"

Proper modifier use is key to surviving these kidney stone scenarios

ESWL is ESWL is ESWL right? Wrong. Multiple stones in each kidney fragmented stones and stent placements are just a few of the things that can complicate coding for extracorporeal shockwave lithotripsy (ESWL).

ESWL represented by 50590 (Lithotripsy extracorporeal shock wave) is one of the most frequently performed procedures in urology practices as well as a popular and effective treatment for renal calculus (kidney stones). Our experts give you the facts for seven tricky ESWL coding scenarios.
Problem: The urologist performs ESWL to break up multiple stones in the same kidney. Can you bill Scenario 2: Stones in Right Kidney and Right Ureter
Scenario 3: Stones in Both Kidneys

Bilateral procedure) in this case.
Remember: Use -LT (Left) and -RT (Right) modifiers to indicate which kidney the ESWL targeted Center says. If the left kidney stone is treated first use 50590-LT; for the second ESWL use 50590-RT-58.
Problem: Three days after an ESWL a patient returns for a stone obstructing the ureter. In the operating room the urologist places a stent. Problem: A patient with another stone presents within the global postoperative period of a previous ESWL. Since it's a new stone the urologist did not write in the preoperative note for the first ESWL that a second ESWL would be staged. How should you report this procedure?

Solution: If the second ESWL is for a different stone in the same kidney and done within the postoperative period of the first ESWL Center advises using modifier -79 (Unrelated procedure) to indicate an unrelated procedure. "It's unrelated to the first surgery " Center says. "Even though it's the same procedure it's a different stone."

Kidney stones do tend to recur most often within months or years after an ESWL treatment. If a urologist performs another ESWL on a patient after the global period for the previous one has expired report code 50590 without modifiers Center says.
Problem: The urologist performs an ESWL for a renal pelvic stone. After one month the physician realizes the stone was incompletely fragmented by the ESWL and decides to perform 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy with or without dilation endoscopy lithotripsy stenting or basket extraction; over 2 cm). The diagnosis for both procedures is 592.0 (Calculus of kidney).

Solution: When a procedure is performed in a global period for the same diagnosis as was linked to the initial procedure - and the second procedure was not planned or staged at the time of the initial procedure - the second procedure must be more extensive than the original procedure to be separately billable. The coder should bill 50081 with modifier -58 appended. This will bring full payment for 50081 but a new 90-day global period would begin.

In this particular clinical scenario modifier -58 is used on a more invasive second procedure during the 90-day global period of the first unsuccessful surgery. This procedure was not prospectively planned or staged and documentation of this fact is not necessary as was needed in Scenario # 3 above.

However: This is a good scenario to bounce off your carriers Delebreau says. "If it's group insurance and it's the same stone I usually don't hesitate to use a -58 because it's related " she says. She had heard different advice about Medicare though so she investigated.

"I checked with some representatives and I explained situations like this where they're going back to re-treat the same stone " she says "and I've been told that I could still use the -58 as long as it's the same stone."
Problem: Using cystourethroscopy and a ureteral catheter a urologist displaces a stone out of the ureter and back into the kidney with plans to perform ESWL on the stone later. How should you code both procedures?

Solution: For the first procedure in which the stone is moved into the kidney use 52330 (Cystourethroscopy [including ureteral catheterization]; with manipulation without removal of ureteral calculus) Center says. "After the cysto and stone manipulation into the renal pelvis using the ureteral catheter the doctor would take the patient over to the ESWL machine " she says.

Since 52330 is bundled into code 50590 bill 50590 for the ESWL and 52330 for the stone manipulation with modifier -59 (Distinct procedural service). 

For further details on this and for other medical coding updates, sign up for a one-stop medical coding guide like  http://www.supercoder.com/

HCPCS 2013: Here’s How Coding For Oncology And Hematology Is Going To Change In The New Year

CPT® 2013 brings in a number of changes for all practices, but for oncology and hematology coders, HCPCS is where they should be focused in right now. Take a look at the coding changes for HCPCS 2013.

Changes in doxil reporting 

HCPCS 2013 deletes both J9001 (Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg) and Q2048 (Injection, doxorubicin hydrochloride, liposomal, Doxil, 10 mg).

In place of Q2048, you get a new code J9002 (Injection, doxorubicin hydrochloride, liposomal, Doxil, 10 mg).

However code Q2049 (Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg) will remain valid for imported Lipodox, which has been used to alleviate the Doxil shortage.

Seperation of Erwinaze from other asparaginase

HCPCS 2013 adds a new code J9019 (Injection, asparaginase [Erwinaze], 1,000 IU) for the chemotherapy drug asparaginase, which is sold under the name Erwinaze.

HCPCS has also updated the definition of the code J9020 as follows:

•       2012: J9020, Injection, asparaginase, 10,000 units
•        2013: J9020, Injection, asparaginase, 10,000 units, not otherwise specified.

New permanent code for Adcetris

HCPCS 2013 adds a new specific code, J9042 (Injection, brentuximab vedotin, 1 mg), for the targeted antibody-drug conjugate Adcetris.

Steer Clear of Ophthalmic Mitomycin Code

HCPCS 2013 revises code J9280 for mitomycin, which is used to treat a variety of cancers. The term "injection" has been added to the definition:

•       2012: J9280, Mitomycin, 5 mg
•      2013: J9280, Injection, mitomycin, 5 mg.

J7178 Completes the Fibrinogen Transition

 

HCPCS 2013 deletes two human fibrinogen concentrate codes:

•       J1680, Injection, human fibrinogen concentrate, 100 mg
•   Q2045, Injection, human fibrinogen concentrate, 1 mg.

 

You now have a new code J7178 (Injection, human fibrinogen concentrate, 1 mg) instead. 

Use code J1741 for IV Ibuprofen

HCPCS 2013 deletes C9279 (Injection, ibuprofen, 100 mg) and adds J1741 (Injection, ibuprofen, 100 mg).

Watch Units for Relistor

HCPCS 2013 adds new code for Relistor, which is used to treat patients with opioid-induced constipation: J2212 (Injection, methylnaltrexone, 0. 1 mg).

To calculate units, you should divide the amount administered by 0.1. So for a 12 mg dose, divide 12 by 0.1 for a total of 120 units.

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