I got this in my e-mail this morning, and am passing along... Not too often this type of opportunity presents itself... If interested give Krissy a call!

Hello. I am working with a small hospital in sought after, breathtaking Wyoming seeking a Physician/Outpatient Coder. Physician coding n a physician clinic or hospital is required.

CPC or CCA certification along with AHIMA or AAPC is preferred. Also prefers someone with work experience as a coder or strong training background in coding and reimbursement. (This position is based in Wyoming, it is not a remote job.)

Competitive salary and benefits package. No State Tax!
If this is something you would like additional information on, please forward me over your updated resume and let me know the best time to get a hold of you to give you the additional details. We also give referral bonuses!
Thanks and I look forward to hearing back from you.
Krissy

Krissy Quinlan
Senior Healthcare Consultant
Management and Executive Search
Contingency/Retained/Interim Placement
Permanent Placement Division

CompHealth
Work:954-837-2635

This is part 5 of the 11 part series from Barry Libman, Inc. I've reposted here, GREAT INFO
*****************************************************************************

by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

How to format your query
All physician queries should be structured in a consistent manner. At a minimum, include:

Patient name
Admission and/or discharge date/date of service
Medical record number/Account number
Date of the query
Name/contact information of coder or person raising the issue/concern.

You then formulate and state the issue you need documented.

How to develop the statement of the issue at the heart of the query:
presented as a question

Must include factual clinical indicators from the chart and must ask the physician to make a clinical interpretation of those facts
The query format should not sounAll physician queries should contain elements of the following:
Must be d presumptive, directing, prodding, probing or as though the clinician is being led to a diagnosis
AND – must instruct the physician where to document the clarification resulting from the query.

The importance of an organization’s physician query policy and procedures

The hospital needs to have good policies and procedures that it can follow when it comes to the use of physician queries. Organizational policy and procedures should address:

Consistency of the query format
Frequency and appropriateness (query fatigue)
Templates
Insuring compliance and addressing non-compliance
Policy maintenance
More important than anything else – the policy must address whether the physical query form becomes a permanent part of the medical record or whether the physicians are required to clarify the query answer in a progress note or somewhere as an addendum.

- See more at: http://www.libmaneducation.com/physician-query-process-part-5-format-of-a-physician-query-developing-the-statement-at-issue-and-the-importance-of-hospital-policies-and-procedures-related-to-the-physician-query-process/?utm_source=LE+Physician+Query+Blog+Series+Eblast+Part+5&utm_campaign=LE+Physician+Query+Blog+Series+Eblast+Part+5&utm_medium=email#sthash.DnAn0Gj6.dpuf

I originally wrote this back in 2014, but still relevant, due to the heat-wave that has been on the rise here in Idaho.... Please be safe my friends, and enjoy! :)

****************************************************************************************************************************

Master coding for heatstroke and related diagnoses in ICD-9-CM and ICD-10-CM

August 5, 2014

By Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP,
AHIMA approved ICD-10cm/pcs training.

Summer and hot weather bring a variety of sun and heat-related illnesses to the forefront of a quick-care or urgent care practice. Coders will need to discern the differences between the signs and symptoms of heat stroke, sunstroke, and other heat-related illnesses in order to choose the correct code in both ICD-9-CM and ICD-10-CM.

The following ICD-9-CM codes, located in category 992, are used to report heat- and light-related signs and symptoms:

• 992.0, heat stroke and sunstroke

• 992.1, heat syncope

• 992.2, heat cramps

• 992.3, heat exhaustion, anhydrotic

• 992.4, heat exhaustion due to salt depletion

• 992.5, heat exhaustion, unspecified

• 992.6, heat fatigue, transient

• 992.7, heat edema

• 992.8, other specified heat effects

• 992.9, unspecified effects of heat and light

These ICD-9-CM codes are separated into a specifically denoted code set for the effects of heat and light in Chapter 17 (Injury and Poisoning), rather than grouped into Chapter 16 (Symptoms, Signs, and Ill-Defined Conditions).

In ICD-10-CM, comparable codes are located in Chapter 19 (Injury, Poisoning, and Certain Other Consequences of External Causes) under category T67 (Effects of heat and light). The ICD-10-CM codes include:

• T67.0-, heatstroke and sunstroke

• T67.1-, heat syncope

• T67.2-, heat cramp

• T67.3-, heat exhaustion, anhydrotic

• T67.4-, heat exhaustion due to salt depletion

• T67.5-, heat exhaustion, unspecified

• T67.6-, heat fatigue, transient

• T67.7-, heat edema

• T67.8-, other effects of heat and light

• T67.9-, effect of heat and light, unspecified

These codes require a seventh character to note the encounter type, using one of the following options:

• A, initial encounter

• D, subsequent encounter

• S, sequela

Coders will need to use two X placeholders in order to complete the code. For example, to report an initial encounter for heat edema in ICD-10-CM, use code T67.7XXA.

The current ICD-9-CM and ICD-10-CM draft codes for these diagnoses are nearly identical in the information they report, even though the codes look very different.

Heatstroke and sunstroke

A patient suffers heatstroke when the body's temperature rises too high as a result of excessive heat exposure. In essence, the body loses its ability to cool itself and overheats. Heatstroke can have a quick onset in severe conditions and situations, especially with extreme physical exertion or exercise. Heatstroke can happen rather quickly, especially if the person becomes dehydrated.

Heatstroke is classified into two separate categories:

• Classic heatstroke: This can occur during a heat wave or very hot weather. Babies, seniors, and patients with chronic health concerns and diagnoses are more susceptible to classic heatstroke than the rest of the population because their ability to thermoregulate is already decreased.

• Exertional heatstroke: This can occur as a result of physical exertion, such as strenuous and/or sustained exercise in a hot environment (indoors or outdoors). Exercise or exertional heatstroke can affect any age group, but tends to affect more physically active people and children, teens, and young adults more than sedentary or older individuals. This is a very common risk, especially for athletes, firefighters, and military personnel that are subject to varied circumstances. Interestingly, patients who have had a heatstroke previously are considered at high risk for recurrence, as the body’s thermoregulation system has already been compromised by the drastic effects of a heatstroke.

The signs and symptoms of a heatstroke can occur individually or as a combination. According to the National Health Service (UK) the following symptoms are some, but not all, of the most commonly identified symptoms seen in heatstroke cases:

• Profuse sweating that abruptly stops

• Accelerated or weak heartbeat

• Hyperventilation with rapid breathing and/or shallow panting

• Muscle cramps

• Skin that is hot, dry, and/or red

• Nausea and/or vomiting

• Sudden headache

• Mental confusion, irrational behavior

• Reduced and/or loss of muscle coordination

• Dizziness, vertigo, lightheadedness, syncope

• Seizure

• Loss of consciousness

• High core body temperature, typically 102°F or higher

Prolonged sun exposure in high temperatures and high humidity, as well as extremely hot or dry weather conditions, can contribute to the risk of a heatstroke. Rapid dehydration and the body’s sweat response make heatstroke a very real possibility.

The weather heat index give us an idea of how the high levels of heat/humidity/dryness affect the body:

• 80°F-90°F, fatigue possible after physical activity or sun exposure

• 90°F-105°F, heat exhaustion, heat cramps, and sunstroke possible after prolonged physical activity or sun exposure

• 105°F-130°F, heat exhaustion, heat cramps, and sunstroke likely after prolonged physical activity or sun exposure

• 130°F and higher, sunstroke likely with sustained exposure to the sun

The media has played an important role in bring heat-related illness/heatstroke to the forefront, especially for young children, the elderly, and animals. Just a few degree increase in temperature can quickly bring on symptoms of a heatstroke.

Coding considerations

When coding for actual heatstroke cases, coders need to carefully review the provider documentation. We can only code what we know. If the provider does not specifically diagnose the patient with heatstroke, but only documents the compilation of symptoms, then we should only code those symptoms. We cannot jump to the “association” of the patient's symptoms to the definitive diagnosis of “heatstroke.”

In ICD-9-CM the guidelines also tell us to “use additional codes” to identify any other associated complications, such as:

• Alterations of consciousness (780.01-780.09)

• Systemic inflammatory response syndrome (995.93-995.94)

Coders should also be aware of the Excludes notes:

• Burns (940.0-949.5)

• Diseases of sweat glands due to heat (705.0-705.9)

• Malignant hyperpyrexia following anesthesia (995.86)

• Sunburn (629.71, 692.76-692.77)

For example, sunburn is reported with its own diagnosis codes and would need to be coded separately in addition to heatstroke.

The ICD-10-CM codes in category T67 have both Excludes1 and Excludes2 notes. The Excludes1 codes are:

• Erythema (dermatitis) ab igne (L59.0)

• Malignant hyperpyrexia due to anesthesia (T88.3)

• Radiation-related disorders of the skin and subcutaneous tissue (L55-L59)

These conditions should never be reported with the codes for heatstroke.

The Excludes2 notes are:

• Burns (T20-T31)

• Sunburn (L55.-)

• Sweat disorder due to heat (L74-L75)

The Excludes2 conditions may occur at the same time as codes from category T67 and can be reported separately.

ICD-10-CM also contains similar instructions to ICD-9-CM for using additional codes to identify associated complications when reporting heatstroke and sunstroke (T67.0-):

• Coma and stupor (R40.-)

• Systemic inflammatory response syndrome (R65.1-)

Physicians will need to explicitly state “heatstroke” as a definitive diagnosis, and not just denote these signs and symptoms presented by the patient in their documentation.

Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, and ICD-10-CM/PCS trainer is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog: http://lori-lynnescodingcoachblog.blogspot.com/.

Hi all,

PMI of Boise, Idaho has two open positions: 1) Coder and 2) Administrative Assistant:

Certified Professional Coder

Certified Coding Position in Boise, Idaho. Remote positions considered. Seeking experienced coder for professional physician services. Demonstrated expertise in surgical and interventional radiology desired. Full time positions with flexible working hours. Specialty coding certification and ICD-10 certification strongly preferred. Benefit package.

Applicants can submit a cover letter and resume by fax to ATTN: Coding Manager 208-472-8172 or e-mail resume@pmiboise.com

Administrative Assistant

Opportunity for experienced administrative assistant in fast paced, large medical billing company. Medical billing experience preferred. Coding experience very desirable. Job requires various support functions for coding department. Normal business hours. Benefit package.

Send resume to resume@pmiboise.com

Good Luck!!!

AudioEducator and myself are happy to extend to you a $20.00 discount on the session.. This makes is only $177.00 for the training (what a DEAL!!!) when you can have the entire group listen in for the same price and get the discount. Use Promo Code "Webb20" at checkout! I hope to "hear you are there" ... :) Use the link below... and I've included a pic of the flyer...

http://www.audioeducator.com/ob-gyn/icd-10-pcs-for-ob-gyn-and-bdominal-pelvic-ultrasound-08-19-2015.html

Get $20 Off On Registering NOW!
(Use Codé "Webb20" at Checkóut )

Speaker: Lori-Lynne A. Webb

Live Webinar
Date: Wednesday, August 19, 2015
Time: 1 pm ET | 12 pm CT | 11 am MT | 10 am PT
Length: 60 minutes

REGISTER NOW

Get Hands-on Coding and Documentation Strategies to Put In Place in Preparation for ICD-10 PCS

With the complete revamp of procedural coding in ICD-10 PCS, good clinical documentation helps to “tell the story”. ICD-10 PCS will provide a more complete clinical picture of patient care, reduce risk, and/or manage risk, in addition to providing a more complete picture of their medical/clinical rècords (HIPAA), and the entire coding/billing processes for reimbursement from 3rd pàrty payers and ìnsurance companies. Hence, becoming proficient in coding ICD-10 PCS is a priority, as the conversion deadline is fast approaching.

Join expert speaker Lori-Lynne A. Webb, in this 60-minute webinar to help you and your facility provide clear cut and accurate coding to substantiate medical necessity and “proof” when claims are submitted to 3rd pàrty carriers (ìnsurance companies) for reimbursement.

This webinar will provide in depth clinical documentation strategies for facilities and Hospital based ultrasound techs and coders to put in place in preparation for the conversion to ICD-10 PCS. The concept behind this is to prepare staff and coders regarding the changes in ICD-10 PCS from ICD-9 Volume 3.

Lori-Lynne will also cover strategies to help providers document more clearly and concisely for the needs of ICD-10 PCS. The rationale behind this educatìon is to help the providers themselves be better prepared to document clearly, so their coders/billers/managers can more easily and successfully choose the correct ICD-10 PCS code and make the transition to ICD-10 PCS more seamless.

This is the nuts & bolts of what is encompassed within a patient vìsit to the facility for OB ultrasound and Gyn and Pelvic ultrasound. The vìsit can be long or short, but the documentation must “tell the story” of why the patient is seeking care, what is being evaluated, why it was evaluated, and the plan of care moving forward. Read more

Areas covered in the session:

· Documenting clearly the “why” and in-depth detail of that care so that providers who view the rècord can understand what was done and why

· Discussion on the providers’ documentation “proof” and “medical necessity” needed to bill 3rd pàrty payer’s for the patients’ vìsit with you

· Correct usage of the ICD-10 PCS tables to “tell the story” of the ultrasound procedure and how it cross codes back to ICD-9 volume 3

· AIUM documentation protocol guidelines for ICD-10 PCS

· Good clinical documentation strategies for use in preparation for the ICD10 PCS changeover onOctober 1, 2015.

· And more

CLICK HERE TO REGISTER

Call us at 1-866-458-2965 and mention SOCAHC01

Get answers to your questions in a Q&A segment after the session

Speaker Bio:

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA approved ICD-10-CM/PCS traìner is an independent coding, compliance, and auditing specialist. She has 20+ years of multi-specialty coding experience and teaches coding, compliance, auditing and billing skills for clinical and clerical staff, utilizing AMA and AHIMA curriculum. She specializes in Women’s OB/GYN services, Maternal Fetal Ultrasound Services, Urology and General Surgical procedures, to include physicìan based and hospital based services. Read More

If you don’t read anything else this holiday season, read this. Documentation improvement is at the heart of any successful ICD-10 coding program, and in this article I will highlight eight key areas of focus about ICD-10 and clinical documentation improvement (CDI).

1) Coding guidelines. While the majority of guidelines are unchanged in ICD-10, one in particular stands out: “a symptom(s) followed by contrasting/comparative diagnosis guideline has been deleted effective Oct. 1, 2014.”

The Centers for Medicare & Medicaid Services (CMS) does not want us reporting symptomology when the patient has a more definitive diagnosis. To be fair, Coding Clinic as well as the guidelines have been instructing us NOT to use symptoms when we had more definitive diagnoses for years; however, the overall guidelines still had this outdated rule up until the ICD-10 guidelines were published. It’s nice to see CMS finally eliminating this inconsistency. No longer does a patient who has “syncope due to either bradycardia or diabetic hypoglycemia” get reported with a principal diagnosis of “syncope.”

2) Coding Clinic. As we move farther and farther into ICD-10, Coding Clinic will become more and more important as a tool to stay on top of the state of ICD-10 coding. Here are some of the lessons learned from recent editions that you need to know now:

Diabetes and osteomyelitis are no longer an assumed relationship.
SIRS due to an infection (example: “SIRS due to pneumonia”) is NOT sufficient documentation for sepsis.
Acute cor pulmonale cannot be coded in the absence of an acute pulmonary embolism, only chronic cor pulmonale can be.
The Glascow coma scale CAN be captured from the EMT documentation as well as “other nonphysician documentation.”
Acute and sub-acute hepatic failure (Code K72.00) should be coded to add severity to patients with acute non-viral hepatitis.
According to CMS, it is entirely appropriate to report metabolic encephalopathy (Code G94.14) in a patient who is suffering from hypoglycemic induced confusion as a result of diabetic hypoglycemia.
Right sided weakness is coded right sided hemiparesis (Code I69.351) when a patient has unilateral weakness as a long term sequela of a stroke.

3) CMS add-on payments associated with new technology: A total of seven approved new technology add-on payments are at play for the coming fiscal year:

CardioMEMS Heart Failure Monitoring System, ICD-10 PCS Code 02HQ30Z, Payment: $8,875.
MitraClip System for cardiac valvular repair, ICD-10 PCS Code 02UG3JZ. Payment: $15,000
.
Lutonix drug-coated balloon for PTA and PTCA, 36 Codes in total, many of which were added
last-minute. How last-minute? They were released by CMS on Oct. 1. Payment: $1,035.72.
Argus II Retinal Prosthesis System, ICD-10 PCS Code 08H005Z and 08H105Z. Payment: $72,028.75.
Blincyto medication for ALL, ICD-10 PCS Code XW03351 and XW04351. Payment: $27,017.80.
Neuropace RNS System Neurostimulator for Epilepsy, ICD-10 PCS Codes 0NH00NZ and 00H00MZ. Payment: $18,474.
Kcentra Coumadin Reversal Medication, ICD-10 PCS Code 30283B1. Payment $1,587.50.

4) What’s gone?

Accelerated /malignant hypertension
Hepatic encephalopathy
Diabetes uncontrolled has been replaced by diabetes, currently hyperglycemic or hypoglycemic.
DRGs 237 and 238: major cardiac procedures with/without an MCC

5) What’s changed?

PVD has switched from defaulting to a venous code to an arterial code.
SVT has gone from being an unspecified cardiac dysrhythmia to actually capturing the correct diagnosis (also now a CC).
A repeat MI has changed from eight weeks to 28 days and may provide an MCC as a secondary diagnosis as long as the principal isn’t also a cardiac diagnosis.
Multiple significant trauma only requires two rib fractures instead of three.
Anemia with cancer now codes to a principal diagnosis of cancer.
Ventilation hours is now broken up into 3 codes: < 24 hours, 24-96 hours and > 96 hours.

6) What’s new?

Persistent Afib (CC)
Chronic pulmonary insufficiency following surgery (MCC)
Sundowning as well as delirium superimposed on a chronic dementia, which is a CC (FO5 acute infective psychosis)
In rare circumstances, a principal diagnosis can qualify as an MCC. Examples include traumatic cerebral edema, saddle pulmonary embolism with acute cor pulmonale, CMV pancreatitis, and candial sepsis.
We also have codes that qualify as a CC when listed as the principal diagnosis: diverticulosis with perforation and abscess, CMV hepatitis, and hydronephrosis with ureteral stricture.
Non-pressure ulcers of the thigh, calf, ankle, heel, midfoot, and lower leg may provide a CC opportunity when the wound character is described in the record (breakdown of skin, fat layer exposed, necrosis of muscle, necrosis of bone, etc.).
DRGs 268 and 269: aortic and heart assist procedures except pulsation balloon with/without an MCC as well as DRGs 273 and 274: percutaneous intracardiac procedures (with and without an MCC) have been added.

7) Combo codes.

A COPD patient receiving antibiotics may not have pneumonia, but the combination code for COPD with acute lower respiratory tract infection is a CC.
CAD with angina is now a combination code, which may include a CC component.
Combo codes specifying a CVA as well as the specific site of the cerebral lesion are a part of ICD-10.
Combo codes for an MI that reflects the site of the occlusion in an ST elevated MI.

8) ICD-10 procedures that cause inappropriate DRG shifts (CDI has no ability to impact):
Example 1

ICD-9: Alcoholic cirrhosis of the liver with bleeding esophageal varices and endoscopic excision/destruction of lesion/tissue of esophagus: DRG 432: Cirrhosis & Alcoholic Hepatitis With MCC
ICD-10: Alcoholic cirrhosis of liver and secondary esophageal varices with bleeding and an occlusion of esophageal vein with extra-luminal device, percutaneous endoscopic approach: DRG 981 Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC.

Example 2

ICD-9: Morbid obesity with laparoscopic gastric banding: DRG 619 to 621 OR Procedures for Obesity
ICD-10: Morbid obesity with alveolar hypoventilation and restriction of stomach with extra-luminal device, percutaneous endoscopic approach: DRG 989. Non Extensive OR Procedure Unrelated to Principal diagnosis.

There are certainly a number of bullet points in this summation that could merit their own write-up, and several of the broad sections listed above could easily be turned into hour-long educational presentations. 2016 will be a critical year for CDI specialists to pay very close attention to Coding Clinic as well as quirks in how the documentation gets translated into DRGs and ICD-10 codes. As we move forward into the coming year, the types of queries necessary to produce quality data collection will continue to evolve.
More than any year in recent memory, both CDS and coders will need to approach each new day as an educational opportunity. If there are any CDI or coding directors out there who had been looking for an excuse to institute mandatory regular coding or CDS meetings, you now have it, especially when the quarterly coding clinics are issued.
About the Author
Allen Frady is a senior consultant for Optum360. His experience includes areas in management, implementation, education and clinical practice. With 20 years in healthcare, he provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.
Contact the Author
Allen.Frady@Optum360.com
Comment on this Article
editor@icd10monitor.com

HAPPY NEW YEAR!!! We wrapped up 2015 in a nice tidy bow, and I haven't had the chance to get some of the info out on the blog.

I have had 4 different articles published from HCPro, and a successful SOGH national conference, in addidtion to the implementation of ICD-10. As a certified ICD-10 training, I have been hip-deep in education with the SOGH and AHIMA national organizations, Webinars for 2 major hospitals in Nevada and California, and getting my new website up and running ( I'm close... so very close) , so I have been neglectful in getting the blog updated.

So, with all of this, in the month of January, I will be "overloading" the blog with lots and lots of good information for all of you.

If you missed it in October of 2015 - here's the link for my "Live" webinar that you can purchase as an on-demand service entitled Unbundling the pregnancy package and managing ICD-10 changes... It is good stuff!

http://hcmarketplace.com/unbundle-pregnancy-package-manage-icd-10-changes

If you want to catch me "live" I have a Webinar on the 2016 update for OB/GYN... January 21, for Audioeducator - 60 minutes and a GREAT price for all in your office.... (see link below.

http://www.audioeducator.com/ob-gyn/ob-gyn-coding-updates.html

In February 2016, I have another webinar schedule with HCPro, on Compliance and documentation risks that were identified in 2015. I can't wait!!! so much is happening!!! Stay Tuned..

Happy New Year and HAPPY CODING!

I found this on Facebook this afternoon, and it has some great information...

http://www.businessinsider.com/why-people-quit-their-jobs-2015-7?utm_content=buffer3a825&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer

Lori-Lynne A. Webb

December 10, 2015

As we prepare for 2016 New Year, there are some challenges left over from 2015 that may need to be reviewed and met. CMS and some of the "big payers" have identified a few of the issues in 2015 post ICD-10 that need some improvement. As we are well aware, documentation continues to be a challenge. Below outlines some of the "risks" that were identified and then the opportunity to implement some of the que/review plans and ideas. The review can bring to light problematic areas and some possible solutions for not only coders, but for your physicians, providers, clinical and office staff.

Risk: The record(s) does not contain a legible signature with credential.

Que/Review: Per CMS' requirements in the Medicare Program Integrity Manual ; Chapter 3 – (3.3.2.4. Verifying Potential Errors and Taking Corrective Actions) Signature Requirements that was just updated and implemented 08/25/2015, "For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable." The instructions from CMS are specifically for CMS, however, these instructions from CMS can easily be put into place as a valid process for all signature authentications for a "best practice" in your office.

In addition, providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process. The signature authentication process described below should also be used for illegible signatures.

A. Handwritten Signature

A handwritten signature is a mark or sign by an individual on a document signifying knowledge, approval, acceptance or obligation.

B. Signature Log

Providers will sometimes include a signature log in the documentation they submit that lists the typed or printed name of the author associated with initials or illegible signature. The signature log might be included on the actual page where the initials or illegible signature are used or might be a separate document. Reviewers should encourage providers to list their credentials in the log. However, reviewers shall not deny a claim for a signature log that is missing credentials. Reviewers shall consider all submitted signature logs regardless of the date they were created. Reviewers are encouraged to file signature logs in an easily accessible manner to minimize the cost of future reviews where the signature log may be needed again.

C. Signature Attestation Statement

Providers will sometimes include an attestation statement in the documentation they submit. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.

Should a provider choose to submit an attestation statement, they may choose to use the following statement:

“I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]__when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

D. Signature Guidelines

		Meets Requirements
1.	Legible full Signature	X
2.	Legible first initial and last name	X
3.	Illegible signature over a typed or printed name (example) John Doe Smith, MD	X
4.	Illegible signature where the letterhead, addressograph, or other information on the page indicates the identity of the signatory. Eg: illegible signature appears on a prescription. The letterhead of the prescriptions lists (3) physicians' names, one of the names is circled.	X
5.	Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by a signature log, or an attestation statement.	X
6.	Initials over a typed or printed name	X
7.	Initial NOT over a typed/printed name but accompanied by a signature log, or an attestation statement.	X
8.	Unsigned handwritten note where other entries on the same page in the same handwriting are signed	X

		Does NOT meet Requirements
1.	Illegible signature NOT over a typed or printed name, NOT on letterhead and the documentation is unaccompanied by a signature log or attestation statement. (example)	X
2.	Initials NOT over a typed/printed name unaccompanied by a signature log or attestation statement.	X
3.	Unsigned typed note with providers typed name	X
4.	Unsigned typed note without providers typed/printed name.	X
5.	Unsigned handwritten note, the only entry on the page	X
6.	"Signature on file"	X

E. Electronic Signatures

Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.

Risk: The Electronic Health Recod was not signed electronically

Que/Review: With some EMRs, it is possible that the provider did not sign off the record or log out within the prescribed time or protocol. If a claim is billed, and the authentication was not done in a timely manner, the 3^rd party may request a refund if such a medical record is submitted during an audit. It is critically important that the electronic record have accurate time/date stamp authentication. In addition to signature authentication, the system should ensure that the electronic record system correctly documents who is accessing and writing/authenticating the medical records/chart. If a signature has been missed, when the provider goes back in, the time-date stamp needs to accurately reflect when the "signature" was performed. As a best practice, it is advisable to print out the medical records/notes and review that all notes, and authentications from all parties are correctly reflected.

Risk: The highest degree of specificity was not assigned to the most precise ICD-10 diagnosis code

Que/Review: At this time, Post implementation that it is imperative that the provider or coder review the notes and apply the most specific ICD-10 diagnosis code. If the codes are input electronically by the provider, then the coder should have the option to suggest a correction, or make the appropriate corrections prior to the claim being submitted. The ICD-10cm guidelines require us to use the most specific code as per the documentation. However, some 3^rdparty payers will still pay the claim if your code is within the same "family". However, it is of best practice to review and implement coding per the current ICD-10cm codeset guidelines regarding specificity and unspecified codes.

I.A. 9.b. “Unspecified” codes Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes

If you do not have a "specific" diagnosis, but have signs and or symptoms, it is appropriate to report those on the claim according to the ICD-10cm guidelines

Section 1B.18. Use of Sign/Symptom/Unspecified Codes

Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. (ref ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 16/17 of 115)

Risk: Discrepancies exist between the diagnoses billed and the diagnoses in the medical record

Que/Review: Having a different diagnosis billed on the insurance claim, not match that which was in the medical record documentation can set the stage for an audit by your 3^rd party payer. These discrepancies can happen as a simple "fumble-finger" error upon data entry. If this is the case, then a correction of the diagnosis should be made and the claim re-processed and the medical records submitted to the carrier for verification of correct and complete documentation and coding.

As a best practice, the coder/biller should be the ones charged with conducting auditing pre and post claims on a regular basis to avoid this issue. If insurance claims are generated solely upon the physicians' billing via an electronic medical record interface to a patient management/billing system, an audit or review system should be in place prior to the claim being generated to avoid this type of claim error. Many billing companies now hold or suspend claims until the charges have been reviewed. This activity can alter or slow down your accounts receivable. Continued ICD-10 education and audit of clinical and coded information should be a required part of the physician or hospital based billing practices.

Risk: Information is missing regarding diabetic complications, or notations if patient is type 1, type 2 or gestational diabetes. (eg diet controlled/Medication controlled/insulin controlled) ISSUE!

Que/Review: In ICD-9, physicians could simply document Diabetes Mellitus – 250.00 – without specifying whether it was Type 1 or Type 2 and whether it was controlled or had complications.

The guidelines for ICD-10cm, require a much higher degree of specificity and more clearly defined clinical documentation.

As coders and providers, chronic condition documentation needs to correlate the complexity of the diagnosis status into hospital and office based care. The element of good documentation must clearly show that the care is delivered, documented and the patient response to that care delivery and/or treatment. If these critical pieces are not coded, the data analysis and statistics will be lost and/or skewed. Currently ICDd10 allows us these area too review for correct coding.

· E08 Diabetes mellitus due to underlying condition

· E09 Drug or chemical induced diabetes mellitus

· E10 Type 1 diabetes mellitus

· E11 Type 2 diabetes mellitus

· E13 Other specified diabetes mellitus

The Diabetes codes in ICD-10-CM can have up to six characters. The first three characters

represent the category, the fourth character identifies the presence of manifestations or complications, and the fifth and sixth characters identify specific types of manifestation.

· Physicians need to first document whether diabetes is primary or secondary to a (separate) diagnosis, or gestational diabetes.

· Documentation should also include the body system affected, and the diabetic complications affecting that body system.

· ICD-10 separates Type 1, Type 2 and Gestational diabetes, along with the system that is impacted.

· If multiple systems are impacted, each must be separately coded.

· ICD-10 requires the provider/physician to document with Gestational Diabetes if it is "diet" controlled, "insulin" controlled or "unspecified" control. This has been an area of concern for MD's to choose the correct code if the patients' gestational diabetes is controlled via " oral medication". ACOG has stepped forward and acknowledged that the provider should code these type of patients as "diet" controlled.

Risk: Clinical documentation does not say if the patient's diagnoses are being "monitored, evaluated assessed or treated".

Que/Review: Upon review, the coder or biller should review and determine if the patient's diagnoses noted in the chief complaint match and be correlated back to the care treatment plans within the chart. If these plans are not being supported by the clinical documentation and medical necessity, this could be a risk area when billing E&M and operative procedures. In the table below, it outlines what the "minimum" documentation requirements should be for "monitoring, evaluation, assessments and on-going treatment plans.

The Care/Treatment plan in each patient chart should reflects the patient's assessed needs and has been updated at each patient visit or hospital stay to include the status of the disease or care process. This documentation is to include all progress (good or bad, and changing needs.)

There is documented evidence of changes in or re-evaluation of treatment needs and/or services during periods of sudden changes in functioning or symptoms at each patient visit or hospital stay.

All treatment needs should be identified in the medical record, and documented if those diagnoses are/are not being addressed, and are prioritized based on importance/severity as determined by the physician or healthcare provider .

There is documented support that the primary care coordination and integrated care is occurring with the primary physical health care provider and any specialty health care providers and/or ancillary services requested, and provided.

In 2016 we can only guess what the payers will want to review, but these issues identified above, were targeted issues in both clinical documentation and in billing/claims from payers in 2015 as areas of interest and non-compliance. Communication, education, awareness, and improvement will always help ensure the most complete information held in the medical and billing records.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/

Q&A follow-up (part 1) Unbundling the OB Package in ICD-10-Clinical Documentation

This is a 2-part series of Q&A that was sent in by our listeners of the Webinar for the HCPro webinar I did entitled " Unbundling the Pregnancy Package in ICD-10" This can be purchased from HCPro and includes some GREAT information! (which includes clinical documentation requirements). We had some great questions, but ran out of time during the Webcast and felt this would be the perfect forum to address those questions, we were unable to during the show.

As we continue to learn and embrace ICD-10cm, many coders are still feeling uncertain in their ability to code OB delivery and ancillary services as easily as we did the ICD-9. ICD-10cm has presented some new documentation challenges. The first 8 Q&A questions are address below.

Q1. During the delivery if the physician documents group B strep positive on the delivery note, do you code O99.824, Z3A.XX, and weeks of gestation?

A1. Yes, this is proper coding for the GBS notation, however, there also needs to be documentation that this was “complicating” the pregnancy. A positive GBS culture is considered a pregnancy complication, it is not considered a high-risk pregnancy complication. Within the documentation the provider should have notated the care associated with GBS, such as the usage of antibiotics prior to or during the delivery itself.

If the provider notes that the patient is a GBS carrier, or does not consider this to be a complication of the pregnancy, then the code Z22.330 Carrier of Group B streptococcus should be used rather than a “complication” code. As a coder, if it is unclear whether the provider is considering GBS a complication at the time of delivery, a query may be in order to clarify.

Rationale: 16. Documentation of Complications of Care; Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.[1]

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Q2. In ICD-10 in references the Z3A.XX "weeks of gestation" code for the "weeks" of delivery. Do we have to put this on every single encounter?

A2. According to AHIMA, the Z3A.XX weeks of gestation code do not have to be appended at every single encounter. However this provides an amazing amount of information and data tracking, not only for your office, but also as transparency for the patient, the payer and the physician. It is incredibly helpful to see that the patient had their 1^st trimester ultrasound at 11 weeks, just by reviewing the claim and/or patient data.

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Q3. What code are you using when there is a current condition that the mother has, e.g., rheumatoid arthritis?

A3. Upon delivery if the patient has another current condition that is affecting the delivery itself, it is appropriate to code the sign, symptom, or diagnosis, however, the documentation in a delivery record needs to clearly state whether or not it is a “complication” to the pregnancy, or simply a co-existing medical diagnosis. In the case above where it is referenced the mother has rheumatoid arthritis, but does not notate a “complication” and the patient has a non-complicated birth, the usage of codes below could be considered.

O80 Encounter for full-term uncomplicated delivery
M06.9 Rheumatoid arthritis, unspecified

Z37.X (birth status)

Z3A.XX (weeks of gestation)

However, if the provider is documenting that the mothers’ rheumatoid arthritis is currently complicating the pregnancy and/or delivery, then the ICD-10 codes could be considered based upon the providers actual documentation/or query

O26.89X Other specified pregnancy related conditions

M06.9 Rheumatoid arthritis, unspecified (or more specificity regarding the RA)

Z37.X (birth status)

Z3A.XX (weeks of gestation)

Rationale: c. Pre-existing conditions versus conditions due to the pregnancy; Certain categories in Chapter 15 distinguish between conditions of the mother that existed prior to pregnancy (pre-existing) and those that are a direct result of pregnancy. When assigning codes from Chapter 15, it is important to assess if a condition was pre-existing prior to pregnancy or developed during or due to the pregnancy in order to assign the correct code. Categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either. It is acceptable to use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter.[2]

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Q4. What if circumcision is done during delivery? Bill that on a separate claim for infant? Is this a covered procedure?

A43. In many cases the OB/GYN does do a circumcision on the baby during the delivery hospital stay. If that provider does perform the circumcision, the patient should receive a charge/billing for that service provided. The circumcision code will be billed on the infant’s claim with the appropriate CPT code, and under the OB/Gyn provider who performed the procedure. Many third party insurance carriers do not cover routine circumcision as a covered benefit, so reimbursement may fall to the patient for the entire charge.

54150 Circumcision, using clamp or other device with regional dorsal penile or ring block

54160 Circumcision, surgical excision other than clamp, device or dorsal slit, neonate (28 days of age or less)

ICD-10 Z41.2 Encounter for routine and ritual male circumcision

Q5. Would you bill with a modifier -51 or -59 for the second baby?

A5. According to the 2015 ACOG coding manual; If vaginal delivery of twins is performed, report CPT code 59400 and 59409-59 or code 59409 with other appropriate X{EPSU}

sub-modifier per payer policy[3]

The rationale behind this is you have provided only 1 antepartum care for 1 patient (mom) However, there were 2 fetus’ and you had separately identifiable delivery for 2 fetus’. Therefore, a global charge of code 59400 is for baby “A”, and a delivery only charge with the appending of mod 59 for baby “B”.

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Q6. If patient is admitted to hospital for complication in second trimester how do we indicate this is not delivery so that when the patient delivers we are not denied for it being already paid as part of the global?

A6. When you are billing for your complication in second/third trimesters and the patient is still pregnant (undelivered) the ICD-10cm diagnosis codes appended will document this. If and when the patient actually delivers you will append the “Outcome of delivery” codes to the claim, as per the ICD-10 coding guidelines.

Rationale: Outcome of delivery; A code from category Z37, Outcome of delivery, should be included on every maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record. [4]

Outcome of delivery Z37- This category is intended for use as an additional code to identify the outcome of delivery on the mother's record. It is not for use on the newborn record.

Type 1 Excludes stillbirth (P95

http://www.icd10data.com/images/note.png

)

Z37 Outcome of delivery

Z37.0 Single live birth

Z37.1 Single stillbirth

Z37.2 Twins, both liveborn

Z37.3 Twins, one liveborn and one stillborn

Z37.4 Twins, both stillborn

Z37.5 Other multiple births, all liveborn

Z37.50 Multiple births, unspecified, all liveborn

Z37.51 Triplets, all liveborn

Z37.52 Quadruplets, all liveborn

Z37.53 Quintuplets, all liveborn

Z37.54 Sextuplets, all liveborn

Z37.59 Other multiple births, all liveborn

Z37.6 Other multiple births, some liveborn

Z37.60 Multiple births, unspecified, some liveborn

Z37.61 Triplets, some liveborn

Z37.62 Quadruplets, some liveborn

Z37.63 Quintuplets, some liveborn

Z37.64 Sextuplets, some liveborn

Z37.69 Other multiple births, some liveborn

Z37.7 Other multiple births, all stillborn

Z37.9 Outcome of delivery, unspecified

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Q7. In ICD-1cm can you bill code 035.3X Maternal care for suspected damage to fetus from drug and code 099.33X Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium at the same encounter? What about code O99.32X Drug use complicating pregnancy, childbirth, and the puerperium?

A7. In ICD-10 pay close attention to what the code is actually stating and look at the “key verbiage” within the codeset.

Usage of code O35.3X Maternal Care for suspected damage to fetus from drug, denotes that the provider is concerned with care provided to the mom, due to “suspected” damage to the fetus from drug. Eg.. the provider may need the mom to have a higher intensity ultrasound of the fetus, or have alternative prescription or social work intervention for a suspected issue with the fetus.

Usage of the code O99.33X is for usage where smoking (tobacco) is specifically noted that the mothers’ usage of tobacco is complicating her pregnancy care and oversight. Usage of the code O99.32X is for usage where drug usage by the mother (this can be any type of drug, eg prescription necessitated, over the counter, herbal, legal, illegal) again is complicating the pregnancy care.

All three of these codes can be coded together, however, when coding O35.3X the provider is required to document the “suspicion” that there may be damage to the fetus from the usage of a particular drug. (eg. Pregnancy and patient is currently prescribed drugs for a seizure disorder that may be harmful to a fetus).

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Q8 When twins are born cesarean on different dates (eg past Midnight) How do I bill for this?

A8. In this instance, the cesarean procedure date/time will be noted for your claim, and with a twin cesarean, the modifier 22 will be appended for the "mothers" record, and it will look similar to this:

CPT: 59514-22 (twin cesarean delivery)

ICD-10 O82.0 Encounter for cesarean delivery without indication

Z37.2 Twins, both liveborn

Z3A.XX Weeks of gestation

However, if Twin A is born at 11:58p.m. and Twin B is born at 12:02 a.m. (next day) the babies records will be denoted with the two different dates. The insurance carrier MAY deny this, so be prepared to submit records with this type of claim. On each of the baby’s records the Date of Service should correspond to the actual date of delivery.

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Q9 In regard to fetal non-stress tests (FNST/NST) , if the physician has not done an interpretation but two RNs have reviewed and documented it, can the hospital facility fee be charged?

A9. The answer to the above is “yes”. The rationale is the hospital owns the FNST/NST equipment and all equipment/ supplies must be billed for when used in the facility. The physician bears the responsibility of doing the interpretation of the test, and documenting the medical necessity/indicator for the testing procedure. The RN’s that reviewed the test, their responsibility lies in getting the service for the usage of the equipment posted in the chargemaster so it will bill out.

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Q10 Would you code Category ll or Category lll fetal heart tones if mentioned in the delivery chart? What is documented to show this affects the management of the mother?

A11. In regard to the actual ICD-10cm coding for a Category II or Category III fetal heart tracing lies in what the provider has actually documented. The ICD-10cm codes do not correspond do the verbiage “category II or category III”. ICD-10cm does have codes to represent abnormalities in fetal heart rate and fetal stress. These codes are found in the code range O76 – O77.9

It is the providers’ duty to provide appropriate documentation of the FNST, and needs to include the medical necessity for the testing (eg diagnosis) . The clinical documentation from the provider must also support the findings if the testing is noted as a category I, II, or III strip, and how management of the patient is impacted due to the findings within the test.

According to the guidelines for OBG management and clinical documentation, A Category I tracing is characterized by a FNST/NST or FHR (Fetal Heart Rate) tracing, during labor (continuous or intermittent) as:

Category I definition:

· baseline rate of 110–160 beats/min

· moderate variability

· no late or variable decelerations

· early decelerations being present or absent

· accelerations being present or absent.

A Category II tracing definition is given to all FHR patterns that cannot be assigned to Category I or Category III. A Category II tracing is neither normal nor definitively abnormal.

Category II definition

· If FHR accelerations or moderate variability are detected, the fetus is unlikely to be currently acidemic.

· If fetal heart accelerations are absent and variability is absent or minimal, the risk of fetal acidemia increases.

· Category II tracings should be monitored closely and evaluated carefully.

A Category III tracing shows aclearly abnormal tracing, and is associated with increased risk of fetal acidemia, neonatal encephalopathy, and cerebral palsy.

A Category III tracing is characterized by

· absent variability plus any one of the following:

recurrent late decelerations
recurrent variable decelerations
bradycardia.

Recurrent late or variable decelerations are defined as those decelerations that occur with 50% or more of contractions. A sinusoidal pattern—characterized by a smooth, sine wave-like, undulating pattern with a cycle frequency of 3–5 waves/min that persists for 20 minutes or longer is also classified as a Category III tracing.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/

[1]ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 16 of 115

[2]ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 54 of 115

[3]ACOG 2015 coding manual page 423

[4]ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 54 of 115

Q&A – from Webinar (Part 2)

2.1 Q: Is billing an e/m along with a 0501F code on an initial OB appointment when the confirmation of pregnancy is done at the same appointment allowed? If not what ways other than servicing the patient at two separate appointments can we be reimbursed for both the initial (global) and the confirmatory appointment?

2.1.1 Q .When a new patient comes to the office with symptoms of pregnancy but doesn't know that she's pregnant and a test determines that she is pregnant does that 1st visit billable or is it part of the global package?

2.1/2.1.1 A: As per the American Congress of Obstetricians and Gynecologists (ACOG) guidelines in which most OB practices try to follow, ACOG presented information (see below) as their recommendation when reporting the confirmation of the first pregnancy visit

“The initial OB visit may be reported as an E/M service under certain conditions. Even if the patient has taken a home pregnancy test, the initial visit may still be billed as an E/M service as you will be officially confirming the pregnancy.

When coding for the “initial ob visit”, there are a few things that have to be taken into consideration. First you have to determine if the patient is there for a confirmation of pregnancy or if the pregnancy has already been confirmed. The second thing that needs to be determined is if the OB record has been initiated. Once this has been established you can determine how the visit should be reported. “http://www.acog.org/About-ACOG/ACOG-Departments/Coding/Reporting-the-Confirmation-of-Pregnancy-Visit

The above information was taken directly from the ACOG web site. However, in my opinion regarding the billing of the E&M along with the designation of the Category II Code 0501F for the initial OB appointment. I consider the “OB start antenatal” at the time the OB flow sheet is initiated, and the physician is performing the comprehensive intake and evaluation process for a new OB patient. This process is certainly separately identifiable from simply “confirming” the pregnancy. A pregnancy confirmation visit would normally be a very short and quick E&M visit, then the patient scheduled at a later date to begin the OB intake and flow sheet process which would include the comprehensive history, exam and plan of care for the current pregnancy.

In my opinion, I would have it clearly defined that the OB “confirmation” of pregnancy is documented as clearly defined/separately identifiable from the “Ob start antenatal” if your office practice chooses to bill for the E&M, and begin the evaluation/OB flow sheet at the same encounter.

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2.2 Q: On a delivery account, would you code RH immunization on the mother's chart if she is given Rhogam during the pregnancy but not at the delivery because baby is also RH negative?

2.2 A: A couple of years back I looked at this issue and from a clinical standpoint, the Rh factor of positive and negative can lead to problems between a mother and the developing fetus. It is commonly referred to as mother-fetus incompatibility, and occurs when the mother is Rh-(negative) and the fetus is Rh+(positive). To help prevent these complications during pregnancy, physicians routinely order the pregnant patient to undergo testing to determine the Rh and ABO blood typing. Once this has been completed, the physician will then determine if having the patient receive the Rho(D) immune globulin.

As for the clinical documentation to be recorded in the chart, if the physician suspects and initiates the RH immunization during the pregnancy it is assumed that the patient and fetus have the incompatibility. However, if this is not the case at the time of delivery, then the provider should notate this finding at that time. However, according to the American Congress of Obstetricians and Gynecologists (ACOG) they have developed a standard guideline of re-administration of the Rho(D) immune globulin product

These standards are:

· The first dose of Rho(D) immune globulin is to be given at 28 weeks’ gestation (earlier if there’s been an invasive event),

· Followed by a postpartum dose given within 72 hours of delivery.

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2.3 Q: With the prenatal visits and the delivery as separate from the OB package you would always append the -59 to the delivery? My understanding is the -59 is used only for procedure to procedure?

2.3 A: The modifier 59 should not be appended to the code(s) when an “unbundled” delivery is billed for at the same time the charges for the antepartum services are billed. In addition, these two services should be billed on two separate claims, identifying the first claim as antepartum services only denoting the span dates you saw the patient. The billing of the delivery should then be on a separate claim showing the “delivery only” as unbundled and dated as the actual date of delivery.

On your claim information note line, you should denote “antepartum care only” and the usage of the codes 59425/59426 or E&M visits denoting the antepartum care. Within the defined parameters of CPT’s definition of modifier 59 there is critical verbiage that I have highlighted below that refers to those services “not ordinarily encountered or performed on the same day by the same individual. The antepartum care and the delivery would not fulfill this parameter for modifier 59.

Rationale: The 2015 CPT Manual defines modifier 59 as follows:

“Distinct Procedural Service: Under certain circumstances, it may be necessary to

indicate that a procedure or service was distinct or independent from other non-E/M

services performed on the same day. Modifier 59 is used to identify

procedures/services, other than E/M services, that are not normally reported

together, but are appropriate under the circumstances.

Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the Same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

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2.4 Q: Are we able to bill an E&M visit if a pap was performed at the post-partum appointment?

2.4 A: In a normal post-partum service visit(s) as part of the global package, a pap smear is commonly performed as ‘routine’ testing during the post-partum period, and the “cervical pap scraping” or procurement procedure performed by the physician/midwife is bundled into the postpartum visit. However, the pap-test itself (e.g. 88175) would be billable.

If the “Pap scraping” is being performed during the postpartum period is a part of a separately identifiable workup for a problem (not pregnancy/postpartum related) then an E&M would be billable and the procurement of the scraping is bundled into the E&M service. A modifier 24 would also need appended as an E&M service provided during a post-op time frame.

Rationale: According to the postpartum care guidelines put forth by CPT and ACOG this is what is normally provided during the postpartum period[1]at the time of the post-partum pelvic exam, that would be when the pap smear scraping/procurement would take place.

· Postpartum visit ( On or between 21 days and 56 days after delivery)

o Pelvic exam and /or weight, BP, breast, and abdomen exam.

o Screen for postpartum depression. Refer for intervention if indicated.

o Screen for domestic violence.

o Discuss sexual activity and contraception with an emphasis on the benefits of long-acting reversible and/or non-reversible contraception.

o Review nutrition and exercise.

o Discuss method of feeding (breast or bottle).

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2.5 Q: If the pap is performed in the middle of the pregnancy is it billable?

2.5 A: If a pap smear is performed during the middle of the pregnancy, it would be billable. The need for a pap smear would be a medically necessary and separately identifiable diagnosis. The Pap smear is normally considered a routine part of pre-natal care. If a patient does have an abnormal Pap result during pregnancy, the physician or provider will determine at that time, what (if any) treatment or procedures can be safely performed based upon the specific diagnosis or reason. The physician or provider may delay treatment until after delivery. In this instance, those E&M visits would be billed as a separately identifiable service outside the global package, the procurement of the pap itself is bundled into the E&M and the pap test itself (e.g. 88175) would also be billed with the diagnosis appended.

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2.6 Q: In the new ICD-10 code set, when do we use the incidental pregnancy code Z33.1?

2.6 A: In the guidelines from ICD-10cm, the codes from chapter 15 and sequencing priority state:

“ Obstetric cases require codes from chapter 15, codes in the range O00-O9A, Pregnancy, Childbirth, and the Puerperium. Chapter 15 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 15 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1, Pregnant state, incidental, should be used in placeof any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.” 2

What this means, is if the patient presents with a separately identifiable diagnosis that is not related to the pregnancy but yet the patient is pregnant, the code Z33.1 should be appended to the claim. A good example of this is; Patient is 23 weeks and 0/7 days pregnant, … and has been diagnosed with an unspecified sprain of unspecified ligament of ankle, initial encounter. This would be coded as: S93.401A Initial encounter

Z33.1 pregnant state incidental

Z3A.23 week’s gestation of pregnancy

2.7 Q: We were told we could not bill for cervical dilation that it is "bundled" into the antepartum. How can we get this paid???

2.7 A: At this time, the CPT code 59200 states "insertion of cervical dilator" is considered a separate procedure. However, according to ACOG, If the service is performed one day (24 hrs) or more prior to a delivery, it can be reported separately. ACOG also states to use modifier 59 appended to the code 59200 on your claim. As a coder, you will need to confirm if the cervical dilation service was performed on the SAME DAY as a delivery, it would be considered part of the global package and not separately reported.

The only other way this service would be billable, is if a non-global physician provided the procedure for code 59200. In this instance, the non-global (not in the same office, or shares the same tax ID # as the global provider) physician would be able to charge for the cervical dilation. 3

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2.8 Q: We have had cases where our MD has been called to the labor area (and sometimes even the emergency room) , as the patient came in thinking she was in labor. However, labor was ruled out. Sometimes the patient had just Braxton hicks contractions which we have a good diagnosis to use. Other times, they thought they were leaking. We were wondering what type of diagnosis can be used for those times patient "thought" they were leaking but really weren’t. now that ICD-10 has become the new codeset?

2.8 A: That is always a tough call, but the patient did arrive to an "emergency" type area. I have used code O99.89 -- Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium, and I have also used O47.XX False labor section within ICD-10 if the provider documents clearly “false labor”. Good documentation from the provider is essential in getting a good diagnosis to support the medical necessity for the patient to be seen and billed for the separately identifiable E&M visit within the global care of the pregnancy. If the provider only documents signs and symptoms, then as a coder you will only code for those that are noted.

In addition, when filing the claim to the insurance carrier, include claim notes to also support your codes and diagnoses (eg vaginal leaking, pelvic pressure, etc..) This addition of information added to the claim helps clarify to the erd party payer/carrier exactly "what" the other disease, symptom or condition is. Don’t forget to add the Z3A.XX weeks of gestation code to provide information to the carrier how far along in the pregnancy the patient is.

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Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.comor you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

[1]American College of Obstetricians and Gynecologists (ACOG) Guidelines for Perinatal Care, Sixth Edition October 2007.

2 ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 51 of 115

3 CPT® is registered trademark of the American Medical Association. http://www.ama-assn.org/

Breast Care and Screening – 2015: Coding & Documentation Strategies

October is Breast Cancer awareness month. In this month, physicians and healthcare professionals have heightened the awareness of patients' to be screened for all types of breast care conditions and breast cancers.

Breast cancer afflicts both men and women. ICD-10cm diagnosis codes now recognize and give us the specificity for location, but also designation between men and women. All of the breast cancer neoplasm codes can be found in ICD-10 under the C-50 codeset. But what about screening? ICD10cm has screening codes for usage with mammogram too.

Z12.31 Encounter for screening mammogram for malignant neoplasm of breast, and

Z12.39 Encounter for other screening for malignant neoplasm of breast.

The Mammogram procedure has been performed for a number of years, and CMS has had strict policies on how it is to be paid. Not only does CPT have Mammography codes, but HCPCS also has 3 codes to be utilized for mammography also. In 2015 CPT gave us codes for digital breast tomosynthesis which provides higher diagnostic accuracy compared ton conventional mammography. The usage of Screening breast tomosynthesis offers better detection of abnormalities with a minor increase in the radiation exposure to the breast tissue. The breast tomosynthesis is routinely used for high resolution, limited angle in the clinical application of breast imaging. It is somewhat similar in the view as a CT type of scan (computerized tomography)

With the inclusion of the new CPT Tomosynthesis codes, these ne CPT codes must be billed in conjunction with the screening mammography HCPCS codes for Medicare. This includes all 2D imaging and 3D imaging. Medicare is also particular that a "screening" diagnosis code be used on these claims and not a diagnostic/problem focused diagnosis.

Prior to October 1^st we were instructed to use only the ICD-9 codes. However, since ICD-10cm is now the valid code-set we need to be using ICD-10cm code Z12.31 or Z12.39 with the appropriate procedure codes.

2015 CPT Codes:

· 77055 Breast Mammography – Diagnostic Unilateral

· 77056 Breast Mammography – Diagnostic Bilateral

· 77057 Breast Mammography Screening Bilateral

· 77061 Digital Breast Tomosynthesis; unilateral

· 77062 Digital Breast Tomosynthesis; bilateral

· +77063 Screening digital Breast Tomosynthesis (add-on code)

· 77058 Breast MRI Imaging Mammography

· 77059 Breast MRI Imaging Bilateral Mammography

· 76641 Breast Ultrasound Unilateral real time with image documentation complete

· 76642 Breast Ultrasound limited

2015 HPCPS Codes

· G0202 Screening mammography, producing direct digital image, bilateral, all views

· G0204 Diagnostic mammography, producing direct 2-d digital image, bilateral, all views

· G0206 Diagnostic mammography, producing direct 2-d digital image, unilateral, all views

As of August 2012, Medicare will now cover screening mammography depending on the age of the female patient, however, Medicare does not cover screening mammography for men.

Women younger than age 35	No Medicare payment allowed for Screening Mammography
Women Aged 35 – 39 years	Baseline Mammogram – Medicare will only pay for one screening for women in this age group
Women Aged 40 and older	Annual Mammogram (or at least 11 months after the last covered screening mammography)

If the patient is determined to need a Medically necessary/diagnostic mammogram, those will be covered as often as deemed medically necessary. Medicare has also put forth an update to the guidelines in helping to distinguish when diagnostic mammography is a covered test. This information was published in June, 2015 in the Medicare claims processing manual. This information is noted as below:

Diagnostic Mammography

A diagnostic mammography is a radiological mammogram and is a covered diagnostic test under the following conditions:

• A patient has distinct signs and symptoms for which a mammogram is indicated;

• A patient has a history of breast cancer; or

• A patient is asymptomatic, but based on the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.

Medicare also requires us to add the new modifier "GG". This modifier allows the patient to have a screening mammogram and a diagnostic mammogram on the same day. If the patient is having a screening mammogram performed, but the radiologist determines a need for a diagnostic mammogram on the same day, Medicare will pay for both services if we add the modifier GG.

In regard to commercial payers, the new digital breast tomosynthesis codes may be considered "experimental" or "investigational" and not be covered for breast cancer screening. As a coder, an inquiry to the carrier should be part of your process if unsure if a specific 3^rd party payer may not pay for this service.

Tips & Strategies for diagnosis coding in ICD-10cm

Now that we are fully engaged in coding for ICD-10cm, we are instructed to use the screening code of Z12.31 (encounter for screening mammogram for malignant neoplasm of breast). In addition iif the patient also has a family history of breast cancer, the Z80.3 family history diagnosis should also be appended to your claim.

When we are coding for a diagnostic mammogram, the screening code of Z12.31 or Z12.39 should never be used in our claims. The signs and symptoms reported in the notes would normally be coded as a priority. However, the claim can be held until the mammography interpretation has been completed by the radiologist, and the coding should be representative of what was noted within the radiologist notes. If the exam is "normal" or "inconclusive" then the coder should still code based upon any signs and/or symptoms noted. (eg. Breast pain). If the radiologist notes a definitive diagnosis such as breast calcifications, then the codes from the R92 code-set should be used.

R92 Abnormal and inconclusive findings on diagnostic imaging of breast

· R92.0 Mammographic microcalcification found on diagnostic imaging of breast

· R92.1 Mammographic calcification found on diagnostic imaging of breast

· R92.2 Inconclusive mammogram

· R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast

Coding of a breast neoplasm based upon mammography should only be done if the patient has a neoplasm that is documented by the radiologist in the radiology interpretation. Coders should not make an "assumptive" leap to code from the C50 code-set, unless specifically noted by the radiologist.

Coding of mammography for female patients that have breast implants also can be confusing. If a patient is having a screening mammogram and also has breast implants, then the Z12.31 will be coded as the primary code, and the code Z98.82 which denotes that the patient currently has breast implants. If the patient is currently having a mammogram due to a problem with their implants, then a complication code, or symptom code would be the diagnosis driver for a diagnostic mammogram, and not a screening mammogram. If the patient had breast implants previously, and has had them removed, the Z98.82 implant status code is no longer valid. ICD-10cm gives us code Z98.86 which informs that the patient has a personal history of breast implant removal.

Breast MRI and Breast Ultrasound

Breast MRI and breast ultrasound codes are not normally used for screening type of services. These methods of imaging are for diagnostic review and for determining a more definitive diagnosis in patients with abnormal mammogram services.

Most Breast MRI services are performed for patients that have dense breasts or are at high risk for breast cancer. Some breast MRI's are performed with a breast lump, that does not show up on traditional mammogram, but can be felt/palpated by the provider. The usage of breast MRI has also been done for patients with breast implants, to avoid the possibility of an implant rupture during traditional mammography.

In 2015 CPT did create new codes for breast ultrasound. The breast ultrasound codes denoted a unilateral "complete" exam and a unilateral "limited" exam. CPT code 76641 breast ultrasound complete, the clinical documentation needs to include the examination of all four quadrants of the breast and regroareolar region. If less than the above was performed, then the limited breast ultrasound code 76642 should be reported. If both breasts have been imaged, as a coder, you have the option to either append the "50" bilateral modifier, or usage of the "rt" and "lt" modifiers for each breast. If you are unsure which to append, contact the 3^rd party insurance payer and request guidance of how they prefer the claims to be coded. Medicare covers breast MRI when clinically indicated and medically necessary. The list below is not an all inclusive list, but ones that Medicare has deemed as a "diagnostic" indicator for usage of breast MRI.

Ø Pain in breast

Ø Lump/mass in breast

Ø Other specified breast disorder

Ø Unspecified breast disorder

Ø Symptoms breast discharge-other

Ø Breast Cancer (NOS)

Ø Breast neoplasm\uncertain behavior

Ø Fibrocystic breast disease

Ø Cystic breast

Ø Hypertrophy breast

Ø Inflammation disease of breast

Ø Mechanical complication of Prosthetic Device/Breast Implant

Clinical Case Study – Clinical Documentation

Case #1

A 39 year old woman with a family history of breast cancer in her sister (who is age 40) has a bilateral mammogram that reveals breast tissue with no suspicious findings. Patient is at increased risk for breast CA due to her family history. Radiologist recommends additional screening test of a breast MRI.

Coding consideration:

CPT: 77057 Screening mammogram ICD-10: Z12.31 screening mammogram

Case #2

A 39 year old woman with a family history of breast cancer in her sister (who is age 40) has a bilateral mammogram that reveals very dense breast tissue with suspicious findings on the left breast. Patient is at increased risk for breast CA due to her family history. Radiologist recommends additional views lt breast mammogram and a breast MRI on the left breast. All are performed same day.

Coding consideration

CPT 77057.GG screening mammogram bilateral ICD-10: Z12.31

CPT 77055.LT diagnostic mammogram ICD-10: R92.2

CPT 77058.LT breast MRI ICD-10cm R92.2

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.comor you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

Internal Fetal Monitoring: CPT Codes 59050 and 59051

IUPC = Intrauterine Pressure Catheter

FSE = Fetal Scalp Electrode

May 17, 2015

Lori-Lynne A. Webb

CPC, CCS-P, CCP, CHDA, COBGC, CDIP

The definition of fetal monitoring involves the use of an electronic fetal heart rate monitor to record the baby's heart rate. Fetal monitoring is most commonly performed late in pregnancy and/or continuously during the intrapartum labor process to ensure a normal delivery of a healthy baby. Fetal monitoring can be utilized either externally or internally within the uterine cavity . External fetal monitoring is done via a fetal non-stress test, and is non-invasive. Internal fetal monitoring is done via fetal scalp electrodes and intrauterine pressure catheters. Internal fetal monitoring is done primarily during the labor processes. However, both internal and external monitoring have been used in some circumstances during labor.

The Intrauterine Pressure Catheter

The intrauterine pressure catheter (aka IUPC) is commonly used during labor and the induction of labor. The IUPC measures and denotes frequency, duration and strength of the contractions and if the patient requires additional medication(s) such as Oxytocin/Pitocin to augment the labor and move it along. The IUPC is a small flexible tube that is inserted into the uterus, to lie between the baby and the uterine wall. This device provides exact measurements of the contractions, unlike external monitors, or a Fetal Non-Stress Test (FNST) that is only monitoring the fetus.

The IUPC is primarily used when labor is progressing slowly or is stalling, or if the physician notices an irregular or abnormal contraction pattern. The IUPC also enables the provider to oversee that the uterine contraction process is strong enough, but not too strong, to ensure a smooth delivery for the fetus and the mother. In addition, an IUPC is typically left in place for the duration of the labor. Once the IUPC is inserted into the uterus, and verified to be functioning correctly, it is then attached to the patient’s leg to secure it.

An IUPC’s measurements are not affected by maternal movement and can also be used with fetal scalp electrodes (FSE) or other internal fetal monitoring devices during labor .

The fetal scalp electrode (FSE)

A fetal scalp electrode (FSE) placement is also billable/codeable under the CPT codes 59050 and 59051 or can be billed as an unlisted procedure with code 59899. An FSE is also bundled into the normal global delivery process. However, if the request of an FSE placement by the attending delivery physician is substantiated in the chart, to have the “consulting” provider insert the FSE, and oversee monitoring of the fetus, the “consulting” provider then has the opportunity to code for the placement, interpretation and , monitoring function of the FSE.

CPT has given coders codes 59050 and 59051 for reporting of fetal monitoring during labor.

• CPT Code: 59050 Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; supervision and interpretation

•CPT Code: 59051 Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; interpretation only

As you will note these two codes have some very important verbiage in them, that this monitoring has to be performed by a “consulting physician”. This means that if an attending provider is performing the entire intrapartum delivery and uses an IUPC or FSE, then it is bundled with the delivery itself. However, if the intrapartum attending provider calls in a specialist to perform or consult on the fetal monitoring, these codes become billable/codeable charges for the “consulting physicians”. You will note that codes 59050 and 59051 do not specifically state the usage of only an IUPC or FSE, but simply “fetal monitoring”. However, these are the most commonly utilized methods of fetal monitoring at this time.

Coding considerations for the consulting physician is to capture all codes that are applicable. In addition to the fetal monitoring, the actual “consultation” E&M can also be billed. As with any consultation you may need to determine if your payers will pay with a “consultation” code or if they would require a hospital based subsequent outpatient or inpatient code. If the consulting provider also performs and interprets a fetal NST, that interpretation service should be coded to capture the consultant physicians’ work for the NST. (59025-26)

Documentation for the FSE and IUPC require the consulting physician to have a separately identifiable documentation noting the request of their expertise by the attending physician. When an IUPC is used during labor, the intent is to measure the exact forces of the contraction(s) and make medical decisions based upon those findings. It must also be noted if the consultant physician is only providing the initial consultation, or if they will be continuing the supervision of the IUPC and that portion of the labor process. This is the difference when determining if to bill code 59050 which includes the written documentation, the supervision, and interpretation of findings. If the supervision is not going to be performed by the consulting physician, then it is appropriate only to bill the 59051, which does not include supervision.

Clinical documentation in the record should contain:

IUPC Uterine Contraction Monitor:

•Intrauterine pressure catheter (IUPC) provides a direct measurement of the intrauterine pressure in mmHg, as well as the frequency and duration of contractions.

•IUPC readings should be verified using uterine palpation as needed.

Acceptable Range

Mild: 15-30 mmHg above resting tone

Moderate: 30-50 mmHg above resting tone

 Strong: 50-75 mmHg above resting tone

•Normal resting tone: 5-15 mmHg

Possible indications for IUPC monitoring include:

•When external methods do not provide accurate monitoring, such as in the case of maternal obesity or frequent changing of maternal position.

•To improve the interpretation of the timing of fetal heart rate decelerations in relation to uterine contractions.

•To determine the strength of contractions in cases of suspected labor dystocia or during labor induction or augmentation.

In the event of a multiple gestation:

•The usage of a monitor capable of simultaneously recording more than one fetal heart rate should be used, and all documentation should note and be separately identifiable of each fetus’ information.

•Abdominal palpation or additional ultrasound may be necessary for location of the placement of the IUPC monitors, or to ensure that each fetus is simultaneously monitored.

•An internal scalp electrode may facilitate monitoring, once membranes are ruptured.

Application of a Fetal Scalp Electrode

•General appearance of patient; and vital signs noted including maternal temperature

•Abdomen exam to include

appearance,

tenderness,

uterine contractions denoting intensity, frequency, and relaxation between contractions.

•Fetal Heart Tones (FHT): baseline, variability, accels, decels (depth, length, alignment to contractions).

•Sterile Vaginal Exam: noting cervical dilatation/effacement/station.

•Fetal vertex presentation is confirmed.

•The FSE is applied to the scalp avoiding the fontanelles or suture lines to minimize scalp trauma.

•All documentation is recorded with date, time, and in depth procedure notes in the patients’ medical record/obstetric notes.

As the coder, if you are not seeing the majority of the documentation needed from the above lists, a query to the provider is in order. Below is a couple of actual clinical documentations to review:

IUPC Scenario

I was called by the attending Midwife, Charlene Ekkles, CNM, to review the fetal strip for her patient that is in labor currently at 41 3/7ths weeks. Upon my review of the strip, Fetal monitoring was still showing variable fetal heart rate decelerations and hard to define uterine contractions that are not picking up on the monitor correctly. Patient is gravida 2, para 1 at 41 and 3/7 weeks with spontaneous rupture of membrane, 75% effaced and 2.5cm dilated. Patient had been laboring for the last 4 hours with no apparent progress and the appearance of incoordinate contractions at this time.

Pt’s abdomen is gravid, pt is obese. Pt appears pale but temperature is normal at 98.3, all vitals are stable. Previous strip shows occasions of incoordinate contractions. I discussed the IUPC catheter with the patient and her midwife, Ms. Ekkles. Patient would like to proceed with IUPC. I obtained consent from patient for the IUPC catheter to be placed.

IUPC placed to monitor contractions and to allow for amnioinfusion for variables if needed. Catheter was placed as per protocol, and EX C/7/0. Good Acceleration noted at the time of IUPC placement.. I have been asked to continue to monitor the patient and oversee the fetal responses in coordination with Midwife and global MD. Total time spent with patient was 15 minutes.

Initial IUPC readings: at 12:29pm after 3 contractions, during peak contractions, I calculated 300MVU’s with a resting tone of 15 mmHG, which appears that the patient has moved into a stabilized contraction pattern. I will oversee and coordinate care with Ms. Ekkles, CNM.

Janna Respoon, MD

Coding Considerations:

CPT:

99251-25 or 99231.25 (consultation or E&M subsequent)

59050 IUPC with supervision

ICD-9cm

659.73 – Abnormality in fetal heart rate and rhythm complicating labor and delivery

661.43 – Hypertonic, incoordinate, and prolonged uterine contractions

645.13 – Post Term Pregnancy

ICD-10cm

O76 - Abnormality in fetal heart rate and rhythm complicating labor and delivery

O62.4 - Hypertonic, incoordinate, and prolonged uterine contractions

O48.0 -Post-Term pregnancy

Rationale: In the scenario above the patients’ global care is being provided by the attending Certified Nurse Midwife. The Midwife, then requested Dr. Respoon’s expertise in the form of a consultation and ultimate care and oversight of the fetal monitoring. The IUPC interpretation is well documented, in addition to the documentation for the consultation/E&M of the patient.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.comor you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

Correct Coding for the Usage of Ultrasound in Office Settings:

7/18/2015

In the physician office setting, coders are very familiar with the concept of coding for chest x-ray and x-ray procedures. However, many more providers are utilizing ancillary services within their office practice to boost revenue, and to make diagnostic testing more convenient for their patients. The usage of ultrasound at the bedside, or within the office practice is becoming more and more common within provider specialty based clinic settings. Most people equate getting an ultrasound primarily in an OB/GYN practice, as it is used frequently for early fetal viewing and for diagnosing female gynecologic issues. However, ultrasound is used in specialty areas such as Ophthalmology, ENT practices, General Surgery, Orthopedic, Urologic and many more provider specialty clinics.

Ultrasound is defined as sound waves with frequencies which are higher than those audible by people. Ultrasound images are made by sending pulses of ultrasound waves into tissue using a probe. The sound echoes off the tissue or areas being scanned and are then recorded and displayed as an image.

Ultrasound (also known as sonography) can be extremely useful in many specialty practices. CPT has given coders a broad range of codes to choose from. In the CPT book set-up the diagnostic ultrasound section is set up similar to that of the traditional x-ray codes. Ultrasound is set up by body areas

· Head and Neck

· Chest

· Abdomen and Retroperitoneum

· Spinal Canal

· Pelvis

o Obstetrical

o Non-Obstetrical

· Genitalia

· Extremities

CPT then gives us codes for

· Ultrasonic Guidance Procedures

· Other Procedures

There are some additional definitions that CPT has included in the guidelines of coding ultrasound. These definitions are

· A-Mode: The A mode is the simplest form of ultrasound imaging and is not frequently used. The ultrasound wave that comes out of the ultrasound probe travel in a narrow straight path.

· M-Mode: or (measurement mode) is a one-dimensional measurement procedure with movement of the scan to record the amplitude and velocity of moving echo-producing structures

· B-Scan: Is a two-dimensional scanning procedure that has a two-dimensional display or image. The B scan is the most common mode of ultrasound and is used often in anesthesia. The complete description of the mode is “real time, 2 dimensional (2 D), B scan”. The 2 dimensional (2D) refers to the fact that the image has two dimensions; horizontal (X axis) and vertical ( Y axis).

· Real-time Scan: is a two-dimensional (2-D) scan with a display of both two-dimensional structure and motion with time.

· Doppler mode: This mode makes use of the Doppler effect in measuring and visualizing blood flow.

o Duplex: a common name for the simultaneous presentation of 2D and pulsed wave doppler information. (Using modern ultrasound machines, color Doppler is almost always also used

· 3-D Fetal Scanning: In 3D fetal scanning, the ultrasound waves are sent straight down and reflected back, then are sent at different angles. The returning echoes are processed by a sophisticated computer program resulting in a reconstructed three-dimensional volume image of the fetus's surface or internal organs. ( similar to CT scan images)

Physicians and providers who have begun utilizing ultrasound in their office practices are finding that having ultrasound readily available enhances the ability to diagnose and treat issues and problems much more quickly than having to send patients out to a traditional hospital setting or practice to have these diagnostic scans performed. In addition, they have found that in the case of post-surgical patients, having this ancillary resource readily available makes follow up care more complete and can negate more extensive follow up services.

In addition to CPT, the AIUM (American Institute of Ultrasound in Medicine) also has practice guidelines available on-line to help guide the practice of diagnostic ultrasound. AIUM and CPT require that all ultrasound examination have a permanently recorded image with measurements and a final written report. If the scan is performed as a global scan, then no modifier are needed. If the technical component is performed, and no formal interpretation is completed, then the modifier TC should be appended to the CPT code when billing. The AIUM has a website dedicated to all the practice guidelines for ultrasound and can be found at http://www.aium.org/resources/guidelines.aspx .

CPT also includes definitions that are used within ultrasound services. The terms “complete”, “limited”, and “follow-up” are noted throughout the ultrasound service codes. As a coder, it is your job to understand what these definitions mean in relation to the scan being performed. CPT guidelines state that if a code states performance of a “complete” scan, then all areas represented within that code will have been scanned and reported back on. If a “complete” scan has not been performed, then a coder needs to report the scan as “limited”.

If you review the CPT code 76700 Ultrasound, abdominal, real time with image documentation; complete, the guidelines state that for this to be “complete” there needs to be real time scans of the liver, gall bladder, common bile duct, pancreas, spleen, kidney, the upper abdominal aorta and inferior vena cava including any abdominal abnormalities. If not all of this was performed, it is then appropriate to use code 76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up). It is inappropriate to append a -52 “reduced services” modifier to radiology ultrasound codes, when a CPT code is available that represents the true work performed.

In coding of ultrasound services, just like in coding of other radiologic services, the term “separate procedure” is still considered to be an “unrelated” or “distinct” service from other ultrasounds performed at that same time. The usage of modifier 51 is inappropriate to be appended to radiologic and ultrasound services. However the usage of modifier 59 will indicate that the subsequent ultrasound procedures are “separately identifiable” and should be documented and billed as such.

As a coder, always find out if you are coding for an ultrasound procedure, and if the equipment that the ultrasound is performed with is, or is notowned by the provider/physician practice. This information is integral to correct billing of the ultrasound services.

· If the equipment is owned by someone other than the physician/provider clinic, the modifier -26 professional Component only, should be appended to the CPT code for billing.

· If the equipment is owned by the provider/physician practice but no written report has been provided, modifier –TC (Technical component only) should be billed and appended.

· If the equipment is owned by the provider/physician practice and all components were performed then a global code should be submitted for billing.

Another coding/billing issue to be aware of is the billing claim should note the POS code to be “11” – Office. (definition: location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis)

Insurance payers such as Blue Cross, Medicaid, Tri-Care and Medicare expect to see the modifier 59 appended when multiple scans are performed and billed. Most payers will deny your ultrasound claims if a modifier 51 or 52 is appended to a claim.

Not only is ultrasound being utilized by itself in office based diagnostic applications, but it is also used for diagnostic/therapeutic applications too. In the section of the CPT book for Ultrasonic Guidance Procedures, code 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation; can and should be coded when used in coordination with a FNA (Fine needle aspiration) or localization. Code 76942 can be used in addition to the FNA code 60100 Biopsy Thyroid, percutaneous core needle.

In Obstetric, Gynecology and Reproductive medicine, providers are utilizing ultrasound guidance for retrieval of oocytes/eggs from the ovary for usage with InVitro Fertilization with code 76948. Maternal Fetal Medicine also uses ultrasound guidance for in-office procedures such as code 76945 for chorionic villus sampling and code 76946 with amniocentesis.

Urology has also begun using ultrasound more and more within the office. CPT code 76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up) is coded when the urologist is looking specifically for kidney stones, bladder, or ureteral or urethral pain. In addition, Ultrasound is used commonly within the urology office to view scrotal and prostate issues.

Operative/Coding Examples

Urology (Established patient)

John Doe presented to my office this am complaining of swelling in the left testicle and some right sided testicular pain for the last week. Has been taking Tylenol for the pain with minimal relief. Visual exam and palpation of scrotum is benign, however, will evaluate with in-office bilateral scrotal ultrasound. After review of the u/sound – diagnosis of bilateral hydrocele and left epididymitis. Patient wants to take a “wait and see” approach. Patient will continue using Tylenol for pain and warm soak/compresses. Will consider other medical or surgical intervention if no improvement. Will see patient back in 30 days.

Scrotal Ultrasound Findings:

Description: Left testicular swelling for one day. Scrotal Ultrasound. Hypervascularity of the left epididymis compatible with left epididymitis. Bilateral hydroceles.
FINDINGS:

The right scrotum/testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm. The right epididymis measures up to 9 mm. There is a hydrocele on the right side. Normal flow is seen within the testicle and epididymis on the right.

The left testicle is enlarged, but still within the normal limits in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm. The left testicle shows normal blood flow. The left epididymis measures up to 9 mm and shows a markedly increased vascular flow. There is mild scrotal wall thickening. A hydrocele is seen on the left side.

IMPRESSION:
1. Hypervascularity of the left epididymis compatible with left epididymitis.
2. Bilateral hydroceles.

Coding Consideration: Office Visit 99213.25 + U/sound 76870

Gynecology (Established patient)

Pt is a25-year-old G0, LMP November 25, 20XX. She comes in today in because of irregular periods and pelvic pain. She is complaining of a three-month history of lower abdominal pain for which she has been to the ED twice. She describes the pain as bilateral, intermittent, and non-radiating. It decreases slightly when she eats and increases with activity. She states the pain last for half-a-day. It is not associated with movement, but occasionally the pain is so bad it has induced vomiting. She has tried LactAid, which initially helped, but then the pain returned. She has tried changing her diet and Pepcid AC. She denies constipation and diarrhea. She has had some hot flashes, but has not taken her temperature. In addition, she states that her periods have been very irregular coming between four and six weeks. They are associated with cramping, pain and heavy bleeding which she is not happy about.

PE: VITALS: Height: 5 feet 5 inches. Weight: 125 lb. Blood Pressure: 120/88. GENERAL: She is well-developed, well-nourished with normal habitus and no deformities. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Deferred.

A/P: Abdominal pain, unclear etiology. Performed Trans-vag ultrasound and right ovary appears normal. Left ovary is enlarged, with cystic type mass. However, given that she has irregular periods that are painful for her, I have recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature of the left ovary. She will followup in 30 days for pain, bleeding and review of enlarged ovary to see if resolved. Patient given script for norco x 10 pills for extreme pain. Will see patient back in 30 days for follow-up and repeat u/sound.

Ultrasound - Transvaginal

Description: Transvaginal ultrasound to evaluate pelvic pain.
EXAM: Transvaginal ultrasound.
HISTORY: Pelvic pain.

FINDINGS: The right ovary measures 1.6 x 3.4 x 2.0 cm. There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right. Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm cystic mass that could represent a large hemorrhagic cyst versus abscess. There is no evidence for left ovarian torsion. There is a small amount of fluid in the cul-de-sac likely physiologic.

IMPRESSION:
1. No evidence for torsion.
2. Large, complex cystic left ovarian mass as described. This could represent a large hemorrhagic cyst; however, an abscess cannot be excluded.

Coding Consideration: Office Visit 99213.25 + U/sound 76830

Thyroid U/sound in office

Indication: Patient with newly diagnosed hyperthyroidism

Technique: A sonogram of the thyroid gland was performed assessing gray-scale appearance and color doppler flow and real time imaging

Comparison: Initial scan

Findings:
The left lobe is slightly enlarged in size measuring [5.1] x [1.6] x [1.5] cm. The right lobe is slightly enlarged in size measuring [5.2] x [1.4] x [1.6] cm.
No nodules are seen. The isthmus is normal in size measuring [1.25] in maximum AP diameter. No adjacent enlarged lymph nodes are seen.

Impression: With the slightly enlarged status of the rt and lt lobe, will send patient for enhanced CT with contrast for more comprehensive views.

CPT Code: 76536

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.comor you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

Coding for Anemia in OB and GYN Patients: The Documentation Challenge

June 21, 2015

The diagnosis coding for anemia is always difficult, but clear documentation from the providers is rarely found in the medical record or operative notes. This problem is amplified when coding for anemia in an OB or GYN patient. Acute blood loss may result in anemia, just as chronic blood loss can result in anemia. The issue for coders is determining if the blood loss has been documented by the provider as “anemia”. In addition, anemia is a separately identifiable condition, that can directly affect the patients’ plan of care and coding of the condition.

The definition of anemia is “a quantitative deficiency of the hemoglobin, often accompanied by a reduced number of red blood cells and causing pallor, weakness, and breathlessness”, but that is not necessarily what is used by clinicians to determine if a patient does or does not have anemia. Providers rely on the hemoglobin and hematocrit blood test results to give them a clinical picture of the patients’ Hgb (hemoglobin) and HCT (hematocrit). The lab values for Hgb and HCT differ for men and women. The values below are considered the “normal limit” upon which an anemia diagnosis would be based. The Hgb and HCT can be found in the (CBC) Complete Blood Count Test lab results as noted in the table below.

	Hemoglobin	Hematocrit
Women	12 - 16 g/dL	35 – 47%
Men	14 - 18 g/dL	40 - 52%

In ICD-9 there are many types of anemia that are shown in the code-set from category 280.0 – 285.9 and in the D50-D89 section in ICD-10. However, in ICD-10 the pregnancy anemia code is listed under code O99.0 and in ICD-9 it is listed as 648.23 Maternal Anemia.

Diseases of The Blood And Blood-Forming Organs 280-289 >

280 Iron deficiency anemias

281 Other deficiency anemias

282 Hereditary hemolytic anemias

283 Acquired hemolytic anemias

284 Aplastic anemia and other bone marrow failure syndromes

285 Other and unspecified anemias

286 Coagulation defects

287 Purpura and other hemorrhagic conditions

288 Diseases of white blood cells

289 Other diseases of blood and blood-forming organs

ICD-9 648.2 Anemia complicating pregnancy childbirth or the puerperium

648.20 Anemia of mother, unspecified as to episode of care or not applicable

648.21 Anemia of mother, delivered, with or without mention of antepartum condition

648.22 Anemia of mother, delivered, with mention of postpartum complication

648.23 Anemia of mother, antepartum condition or complication

648.24 Anemia of mother, postpartum condition or complication

In ICD-10 the anemia codes are held within the codes of D50 – D59.

D50-D53 Nutritional anemias

D55-D59 Hemolytic anemias

D60-D64 Aplastic and other anemias and other bone marrow failure syndromes

D65-D69 Coagulation defects, purpura and other hemorrhagic conditions

D70-D77 Other disorders of blood and blood-forming organs

D78-D78 Intraoperative and postprocedural complications of the spleen

D80-D89 Certain disorders involving the immune mechanism

The ICD-10 codes for Anemia in pregnancy are found in these codes

O99.0 Anemia complicating pregnancy, childbirth and the puerperium

O99.01 Anemia complicating pregnancy

O99.011 is a specific ICD-10-CM diagnosis code O99.011 …… first trimester

O99.012 is a specific ICD-10-CM diagnosis code O99.012 …… second trimester

O99.013 is a specific ICD-10-CM diagnosis code O99.013 …… third trimester

O99.019 is a specific ICD-10-CM diagnosis code O99.019 …… unspecified trimester

O99.02 is a specific ICD-10-CM diagnosis code O99.02 Anemia complicating childbirth

O99.03 is a specific ICD-10-CM diagnosis code O99.03 Anemia complicating the puerperium

If a patient with acute bleeding (hemorrhage), loses enough blood to become anemic, the diagnosis of acute blood loss anemia is appropriate. In addition, patients who have a preexisting anemia (chronic or acute) and become more anemic due to bleeding or hemorrhage following surgery or a delivery, it is still classified as a blood loss anemia. Blood loss during surgery and delivery is expected, but not all surgical blood loss causes an anemia, does a hemorrhage necessarily cause an anemia. Not all anemia diagnoses requires a treatment such as a transfusion.

Coding Blood loss anemia after surgery can be challenging, as the coder should never assume this is a postoperative complication. Many of the surgeries in OB and GYN are expected to have high blood loss. If this is the case, then the physician should document this with the correct documentation. If this is the case, the correct code assignment is 285.1. If acute blood loss anemia is a complication of surgery , then the documentation should reflect the complication and it would then be correct to assign codes 998.11 and code 285.1.

If the physician documentation only states "postoperative anemia", the coder should only code 285.9, Anemia, unspecified. Again, a coder cannot “assume” that the anemia is a blood loss anemia. The most important guideline for a coder to follow is if the physician does not describe the patient as having an anemia, a hemorrhage or a complication of surgery, do not assign any codes for an anemia or blood loss.

In OB and GYN practices these are the most common reasons for an anemia

· Menstruation causes the loss of red blood cells with the sloughing off of the uterine lining every month, and if there is a heavy blood loss every 28 days, some women are not able to replace it quickly enough, therefore becoming anemic (eg blood loss anemia, not related to a surgery or trauma)

· Pregnancy increases the risk of iron deficiency anemia because the iron stores have to serve both the increased blood volume for your own body as well as be a source of hemoglobin for the fetus.

· Post-Operative Hemorrhage is a common reason for an anemia in an OB/GYN patient, however the physician would also need to notate the cause/hemorrhage relationship in the medical record and if the hemorrhage was directly related to a surgery and/or delivery.

In pregnancy, it is normal to have a mild or mild-persistent anemia. Pregnancy related anemia can be mild, but may convert into a more severe anemia from low iron or vitamin levels. When coding a symptom code in a pregnant or gynecology patient, they may only discuss symptoms such as “feeling tired/fatigued” or “weak”. If the provider does not specifically state this is an anemia, then anemia should not be coded, or forward a query to the provider to determine correct coding. (eg symptom code, or anemia code) If the anemia IS severe but is not treated or evaluated, the “hidden” anemia may increase the risk of a serious complication such as a pre-term delivery, or an antepartum or postpartum hemorrhage.

There are several types of anemia that can develop in the antepartum period they are

· Iron-deficiency anemia

· Folate-deficiency anemia

· Vitamin B-12 deficiency

If the provider notes that the antepartum patient does have an anemia, the coder should query the provider to get specificity on the anemia, and have the record amended to reflect the correct diagnosis. If antepartum anemia is an ongoing part of the antepartum care, this diagnosis should also be reflected consistently in the OB antepartum flow sheet documentation. Coders cannot make the causal relationship “jump” to anemia, even though a CBC or other lab test may indicate a low Hgb or HCT. Only a provider can document what type of anemia it is.

In ICD9 we only have the choice of coding to codes set 648.2X which states “maternal anemia complicating pregnancy, childbirth, or the puerperium. Yet, in ICD-10 we have the option to code with more specificity for distinguishing a complication of the antepartum period/pregnancy, the delivery/childbirth, or the postpartum/puerperium time frame.

· O99.01X Anemia complicating pregnancy,

· O99.02 Anemia complicating childbirth

· O99.03 Anemia complicating the puerperium

ACOG (American College of Obstetrics and Gynecology) has stated that in a non-pregnancy related blood loss, the two main objectives of managing an acute onset of abnormal uterine bleeding are 1) to control the current episode of heavy bleeding and 2) to reduce menstrual blood loss in subsequent menstrual cycles. So with this information, coders really need to review carefully any references to an “anemia”. The anemia referenced in a Gyn patient may be the primary diagnosis for a surgical treatment, but the secondary reasons behind the blood loss, may be endometriosis, polyp or even a neoplasm of the uterus, cervix or vaginal area.

Below you will find some quick case examples, and you will note we have not provided any diagnoses with them. These examples are for you to consider, and ponder the question of whether or not to query for additional information. These case studies are relevant for those coding both for the facility, and for a physician office type setting.

Quick Case Example/Coder Q&A:

A 35-year-old mother of three undergoes a transvaginal hysterectomy for prolapsed uterus and menometrorrhagia. Her hemoglobin level is 11.5 g/dL before surgery and 9.0 g/dL after surgery.

1. Does she have acute blood loss anemia?

2. Was the procedure complicated by unexpected hemorrhage?

3. Should the coder query?

Answer: She does have acute blood loss anemia; supported by the fact that she lost an additional 2.5 g/dl of blood post surgery. However, the patient was anemic pre-operatively too. In addition, the patient sustained additional blood loss due to the hysterectomy surgery. The issue with the above case is the physician did not clarify if this was an “expected” amount of blood loss, or if this was an “unusual or hemorrhagic” amount of blood loss that occurred within the surgery, or if the blood loss would be considered a “surgical complication”. To be able to code the diagnosis correctly the physician would need to amend the documentation to reflect the blood loss's significance and any causal relationship with the hysterectomy ( anemia, post op or intra op hemorrhage) and if the blood loss is a “complication” . Since the coder does not have enough information to adequately code the scenario a query should be done prior to any billing going out.

Quick Case Example/Coder Q&A

A 31-year-old female admitted to the hospital with pelvic pain and vaginal bleeding. The patient had a positive hCG and hCG titer of about 18,000. Patient complains of excessive bleeding – soaking 2 pads prior to presentation at the Emergency dept. Patient examined by OB provider to rule out ectopic pregnancy or rupture of corpus luteal cyst. CBC performed, Hgb = 12 HCT 35%. Abdominal US was performed, ruptured ectopic pregnancy was established. The patient was taken to surgery and a laparotomy was performed with confirmed findings of a right ruptured ectopic pregnancy. The right salpingectomy was performed with no complications. The patient received 2 units of red packed cells. Hbg post surgery = 7.9 Hgb post transfusion = 9.2
Diagnosis: Right ruptured ectopic pregnancy with hemoperitoneum and anemia secondary to blood loss.

1. Does she have acute blood loss anemia?

2. Was the procedure complicated by unexpected hemorrhage?

3. Should the coder query?

Answer: She does have acute blood loss anemia; supported by the fact that she lost 4.1 g/dl of blood between arrival and post surgery. The patient did have additional blood loss due to laparoscopic surgery. The physician did not clarify if this was an “expected” amount of blood loss, but stated she had a hemoperitoneum which can be considered “causal” for hemorrhage prior to surgery. The documentation did not reflect an “unexpected” hemorrhage, so this blood loss would not be considered a complication of surgery. In addition, the physician also noted the anemia secondary to blood loss in his final diagnosis. This case would not necessarily require a query.

Quick Case Example/Coder Q&A

PREOPERATIVE DIAGNOSIS: Postpartum hemorrhage.
POSTOPERATIVE DIAGNOSIS: Postpartum hemorrhage.
PROCEDURE: Exam under anesthesia. Removal of intrauterine clots.
ANESTHESIA: Conscious sedation.
ESTIMATED BLOOD LOSS: Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.
COMPLICATIONS: None.
INDICATIONS AND CONCERNS: This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery. I was called for persistent bleeding and passing large clots. I examined the patient and found her to have at least 500 mL of clots in her uterus. She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her. I did advise her that I would recommend they came under anesthesia and dilation and curettage. Risks and benefits of this procedure were discussed with the patient. All questions were adequately answered and informed consent was obtained.
PROCEDURE: The patient was taken to the operating room where satisfactory conscious sedation was performed. Bimanual exam revealed moderate amount of clot in the uterus. I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed. I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found. At this point, the procedure was terminated. Bleeding at this time was minimal. Preop H&H were 8.3 and 24.2. The patient tolerated the procedure well and was taken to the recovery room in good condition. Will continue close observation for blood loss and transfuse if needed.

1. Does she have acute blood loss anemia?

2. Was the procedure complicated by unexpected hemorrhage?

3. Should the coder query?

Answer: She does have acute blood loss anemia; supported by the fact the physician noted the Hgb of 8.3 and HCT of 24.2. The patient did have additional blood loss of 200 ml. during the procedure, and was documented that a total blood loss of aprox 2000 ml happened post delivery, but prior to the return to the OR for clearing of the clots . It is clearly stated this is a post-partum hemorrhage, and interventions were implemented. It appears from the documentation the hemorrhage was an “unexpected hemorrhage” post delivery. A query should be made to the physician to clarify the hemorrhagic “complication” before appending any diagnosis for hemorrhage complicating surgery.

Interrupted Pregnancy: Tubal, Ectopic, and other Abnormal Pregnancies

04.26.2015 - Lori-Lynne Webb

The definition of an abnormal pregnancy is when a fertilized egg does not attach within the normal area of the uterus, and attaches in other abnormal areas within the internal female genital organs, or pelvic cavity. There have been cases where the egg can attach within the abdominal cavity, stomach area or even the cervix. Ectopic pregnancies occur in one out of every 50 pregnancies within the United States, however some statistics state it happens more frequently. Worldwide statistics note that abnormal pregnancy to be more representative of 1 in every 100 pregnancies.

A pregnancy that has attached in an inappropriate environment outside the uterus has an extremely low change of survival, and can cause extreme complications within the mother. In the best interest of the mother, immediate treatment of an abnormal pregnancy requires definitive and speedy diagnosis, then a decision and undertaking of the surgical or medical management.

The most common names that you will encounter for an abnormal pregnancy are:

· Abdominal Pregnancy

· Tubal Pregnancy

· Ectopic Pregnancy

Within an “ectopic” pregnancy the egg can attached under these sites within the pelvic organ itself. (see illustration)

· Cervical

· Ovarian

· Ampullary

· Cornual

o Interstitial

· Isthmic

· Fimbrial

The causes of an abnormal pregnancy are not fully understood or known, but are attributed to being caused by a blockage or slowed movement of a fertilized egg through the fallopian tube to the uterus.

If the diagnosis of an abnormal pregnancy is confirmed extremely early, medical management of the condition can be undertaken. The drug, methotrexate may be given, in which this allows the body to absorb the pregnancy tissue. If caught soon enough this may be enough to save the fallopian tube or ovary, but is dependent upon how far the abnormal pregnancy tissue has developed.

If the pregnancy has progressed further than medical management can correct, then surgical intervention will be needed. Oftentimes, the surgical intervention requires removal of part or all of the fallopian tube and/or ovary. If the tube has been ruptured and is bleeding, emergent surgery may be required, rather than a planned admission for surgical management .

Surgical management of an abnormal pregnancy can be performed as an “open” or incisional operative case, or as a laparoscopic surgery. Either surgical approach/procedure involves removing the area of the abnormal pregnancy and may require removal of a fallopian tube or ovary.

Coding for Abnormal Pregnancy Diagnosis and Surgical Procedures

CPT has provided us surgical procedure codes for the treatment of these type of pregnancies with the codes

Ø 59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach

Ø 59121 Surgical treatment of ectopic pregnancy; tubal or ovarian without salpingectomy and/or oophorectomy

Ø 59130 Surgical treatment of ectopic pregnancy; abdominal pregnancy

Ø 59135 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy

Ø 59136 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of uterus

Ø 59140 Surgical treatment of ectopic pregnancy; cervical, with evacuation

Ø 59150 Laparoscopictreatment of ectopic pregnancy, without salpingectomy and/or oophorectomy

Ø 59151 Laparoscopictreatment of ectopic pregnancy, with salpingectomy and/or oophorectomy

As you can see from the listing above each one of these codes is very specific as to what the procedure approach is, and what areas are being addressed in the management of the diagnosis. If you note with codes 59135 and 59136 it is addressed for an interstitial pregnancy, which is defined as a pregnancy location outside the normal area of the uterus but within the uterine cavity in one of the upper “horns” of the uterus and has attached within that small muscular area where the uterine wall and the fallopian tube meet. An interstitial pregnancy should not be confused with a pregnancy that is diagnosed as an isthmic tubal pregnancy. An isthmic tubal pregnancy is further down within the tube at the area of the isthmus.

Coders need to be diligent in understanding where the pregnancy is located prior to coding for the operative procedure. If the physician has not provided clear documentation where the abnormal pregnancy is located, the coder should query the physician and ask for the operative report be amended to clearly confirm the diagnosis and anatomic location. Another caveat for coding procedures for abnormal/ectopic pregnancy is to carefully review if both the tubes and ovary are removed, and if there are any further diagnoses that need coded in regard to the specific procedure.

The diagnoses for ectopic procedures in ICD-9 are very straightforward and are contained in the code set of codes 633 Ectopic Pregnancy. All of the codes within the ectopic pregnancy codes clearly state abdominal, tubal, ovarian, other and unspecified ectopic pregnancy. However, if the physician has not specified what type of ectopic it is, the coder should query and have the physician correct the record by amending the medical operative record and diagnosis.

633 Ectopic pregnancy

· 633.00 Abdominal pregnancy without intrauterine pregnancy

· 633.01 Abdominal pregnancy with intrauterine pregnancy

· 633.10 Tubal pregnancy without intrauterine pregnancy

· 633.11 Tubal pregnancy with intrauterine pregnancy

· 633.20 Ovarian pregnancy without intrauterine pregnancy

· 633.21 Ovarian pregnancy with intrauterine pregnancy

· 633.80 Other ectopic pregnancy without intrauterine pregnancy

· 633.81 Other ectopic pregnancy with intrauterine pregnancy

· 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy

· 633.91 Unspecified ectopic pregnancy with intrauterine pregnancy

As we transition to ICD-10 the clinical documentation becomes much more important for coders to accurately code and bill for ectopic pregnancies and include all pertinent diagnoses.

The ICD-10 crosswalk for ectopic pregnancies is not much larger than that held in ICD-9, but again requires the coder to know the type of ectopic pregnancy. This listing below shows the ICD-10cm codes that are assigned to Abdominal, Tubal, Ovarian, Other ectopic, and Unspecified Ectopic pregnancy. As you can see this listing is set up nearly identical to the ICD-9 section, but is more comprehensive in regard to the codes themselves. The other caveat to coding in ICD-10 is that the alpha character “O” denotes the code set followed by a “zero” numeric character. This can be confusing when performing diagnosis coding with the ICD-10 code set.

Ectopic pregnancy

· O00.0 Abdominal pregnancy

o Excludes1: maternal care for viable fetus in abdominal pregnancy (O36.7-)

· O00.1 Tubal pregnancy

o Fallopian pregnancy

o Rupture of (fallopian) tube due to pregnancy

o Tubal abortion

· O00.2 Ovarian pregnancy

· O00.8 Other ectopic pregnancy

o Cervical pregnancy

o Cornual pregnancy

o Intralegamentous pregnancy

o Mural pregnancy

· O00.9 Ectopic pregnancy, unspecified

At this point in time, where we are transitioning from ICD-9 to ICD-10cm it is wise to dual code in both ICD-9 and ICD-10cm to become familiar with the new code set and how the codes cross walk between the two code sets. The GEMS crosswalk cannot be counted on to be accurate. The only way to fully ensure you are coding correctly in ICD-10cm is to do the full look-up process for each code that you have chosen in ICD-9.

Operative Cases - applying your knowledge

Case #1:

A 31-year-old white female admitted to the hospital. Patient presented with pelvic pain and vaginal bleeding. After workup the diagnosis of right ruptured ectopic pregnancy with possible hemoperitoneum was established. Ultrasound performed in the Emergency Department confirmed ruptured tubal pregnancy. There was no gestation products noted in the uterus. The patient was taken emergently to surgery and a laparotomy was performed to include a right-side salpingectomy with no complications - confirmed findings of a right ruptured ectopic pregnancy.

CPT procedure:

59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach

Final Diagnosis:
ICD-9: 633.10 Tubal pregnancy without intrauterine pregnancy

ICD-10cm: O00.1 Tubal pregnancy

Case #2

The patient is a 22-year-old who presented to our office this a.m. with extreme left sided pain and a positive pregnancy test. A quick-peek ultrasound in our office confirmed a mass near the left tube with a possible ruptured left ectopic pregnancy. Ultrasound did not show any gestational contents within the uterus. Patient was admitted to day surgery for emergent diagnostic laparoscopy.

Operative Findings: Tortuous left fallopian tube with evidence of ruptured ectopic pregnancy and extensive adhesions.

Procedure: After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered. She was examined under anesthesia. An 8-10 cm anteverted uterus was noted. The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion for a laparoscopic diagnostic procedure. Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus. The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity. Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water. No peritoneum was obtained without difficulty using 4 liters of CO2 gas. The 5-mm trocar and sleeve were then advanced in to the intra-abdominal cavity and access was confirmed with the laparoscope.

The above-noted findings were visualized. A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point. Under direct visualization, the trocar and sleeve were advanced without difficulty. A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep. Care was undertaken, as not to disturb the uterus or bladder. The peritoneal fluid was aspirated and sent for culture and wash and cytology. The abdomen and pelvis were surveyed with the above-noted findings. Evidence of tortuous adhesions of the ovary and fallopian tube were noted and gently lysed. Ruptured Left tubal ectopic pregnancy was noted in the left fallopian tube near the fimbrii. Salpingectomy removal of the entire right tube was undertaken. Entire left fallopian tube with fimbrii and products of conception forwarded to pathology. Hemoperitoneum was noted and suctioned. All sites cauterized as needed. The instruments were removed from the abdomen under good visualization with good hemostasis noted. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

CPT procedure:

59151 Laparoscopic treatment of ectopic pregnancy, with salpingectomy and/or oophorectomy

Final Diagnosis:
ICD-9: 633.10 Tubal pregnancy without intrauterine pregnancy

ICD-10cm: O00.1 Tubal pregnancy

Case #3

Patient is a 40 year old Gravida 3 followed by me for a possible left ovarian pregnancy for the last 2 weeks status post methotrexate. Today she presented with acute LLQ pain. Repeat u/sound finding of a solid mass adjacent to the ovary, and no free fluid in the pelvis. I decided to undertake a laparosopic evaluation. Patient was consented and admitted to emergent day surgery.

Findings: Hemorrhagic right ovary with rupture, Right ectopic tubal pregnancy

Procedure: Patient was placed in low lithotomy position, and sterile prepped and draped. A small infraumbilical incision made, and a veress needle was inserted. Attempts at insufflation were unsuccessful, and after 3 attempts at placement, it was decided to proceed with open hasson trocar. Peritoneal cavity was entered bluntly and the Hasson was placed. Peritoneum was insufflated and a 10mm trocar placed under direct visualization to the left of the umbilicus and a 5mm to the right. A suprapubic trocar was then placed. Pelvis was inspected and right tube and ovary appeared normal.

On the left, the adnexa was very stuck lateral to the sigmoid, rectum and deep into the cul-de sac. After some manipulation it was noted that both the ovary and tube were very enlarged and purple. There was a definite separation between the tube and the ovary however both were involved. The ovary was densely adherent to the left pelvic sidewall and had essentially and a hemorrhagic polycystic ovary appearance. It was determined due to the extensive nature of the hemorrhage, we would remove the ovary in addition to the tube. The left tube had a ruptured ectopic pregnancy within the mid-section of the tube with pronounced tubal dilation but no definite rupture of the tube at this time. The lateral peritoneum to the sigmoid was incised with a scissors to try to mobilize the sigmoid medially to get to the tube and ovary. With some blunt dissection the left tube was freed and also the left ovary. A 10mm ligasure was brought across the tube near the uterus and cut, then brought along the mesosalpinx and the tube was excised. The same procedure was performed to excise the ovary. Both specimens were removed through the umbilical port site. The Adnexa was irrigated and hemostasis appeared good. Blood loss was around 50cc. Patient taken to recovery in satisfactory condition.

CPT Procedure:

59151 Laparoscopic treatment of ectopic pregnancy, with salpingectomy and/or oophorectomy

ICD-9: 633.10 Tubal pregnancy without intrauterine pregnancy

256.4 Polycystic ovaries

ICD-10cm: O00.1 Tubal pregnancy

E28.2 Polycystic ovarian syndrome

April 9, 2015

Taxonomy Codes – A quick code-set refresher

In the world of medical billing and credentialing for provider or group specialties, taxonomy codes have a very important role in the process. HIPAA standard code sets specify many areas to utilize a “standard” for transactions. In many cases a taxonomy code is required to reimburse a claim, however, the reporting requirements for a taxonomy code may vary between the insurance carriers and 3^rd party payers.

What is a taxonomy code?

Taxonomy codes were created for use with the HIPAA transaction code sets to specifically categorize healthcare providers and specialties for transactions related to health care. The taxonomy codes are separated into two sections:

· Individuals/Groups of Individuals

· Non-Individuals

Next is the tiered levels that give specificity to the individuals/groups of individuals and the non-individuals and the type of service/specialty that most correctly represents them. Within the tiered levels the higher the code level (level 1 – level 3), the more specific the classification of the practice, provider type, facility or agency .

Ø Level 1, provider type:

o Level 1 provider type is the most “generic” for specificity. It provides a general/generic code number for occupations and services such as Emergency Medicine, Family Medicine, Dermatology, Dental Provider, Chiropractic Provider, and many more for the Individuals/Groups of Individuals.

o Level 1 non-individuals includes those things such as agencies, ambulatory Health care facilities, hospitals, transportation services, healthcare suppliers

Ø Level 2, classification:

§ The level 2classification of the code set for individuals/groups of individuals provides even more specificity to the service or occupation. The code that is more specific to the practice type may be initially found under the primary level 1 classification, such as Physician Assistant & Advanced Practice Nursing, then the classification is separated into more specialty based specific provider types within level 2, such as Clinical Nurse Specialist. These types are then drilled down into types such as (not an all inclusive list)

· Acute Care

· Adult Health

· Emergency

· Neonatal

· Pediatrics

§ Level 2 specificity for non-individuals such as a level 1 ambulatory health care(s), the specificity would fall into categories such as

§ Ambulatory surgery center

§ Birthing Center

§ Critical Access Hospital

§ Home Infusion

§ Foster Care

Ø Level 3, area of specialization - this category is the highest level of specificity. The specificity for the individuals/groups of individuals category represents those services at the most descriptive level such as a level 1, Nursing Service Providers; Level 2 , Registered nurse; Level 3 types such as (not an all-inclusive list

§ Diabetes Educator

§ Gerontology

§ Obstetric High-Risk

§ Oncology

§ Ambulatory Care

§ Orthopedic

Ø Level 3 specificity for Non-Individuals would be found in Level 1, Hospitals; Level 2, General Acute Care, Level 3 type such as

§ Children’s’ Hospital

§ Critical Access Hospital

§ Rural Hospital

§ Women’s Hospital

Taxonomy Code Structure

Once we understand the levels of specificity to choose from, the code structure is ten characters in length, and are alphanumeric. All taxonomy codes end with the letter “X”. The National Uniform Claim Committee or NUCC is the organization that maintains the integrity and structure of this particular code set. Taxonomy codes are also utilized on credentialing applications and are set up for use with the ASC X12N HIPAA transaction and other HIPAA mandated transaction requirements. When providers or agencies apply for a National Provider Identifier from CMS (NPI number) adding a taxonomy code is helpful, but not required.

The first four characters in a taxonomy care represent a “level 2” classification, the next 5 characters are representative of the “level 3” specificity and the last character is always “X”. If we only want to assign a “level 2” code for our OB/Gyn group practice, we could choose the taxonomy code of 207V00000X. The definition for this code in the NUCC table states:

Obstetrics & Gynecology: An obstetrician/gynecologist possesses special knowledge, skills and professional capability in the medical and surgical care of the female reproductive system and associated disorders. This physician serves as a consultant to other physicians and as a primary physician for women.

Now if we want to get a more specific taxonomy code assigned to our Maternal & Fetal Medicine specialists we would assign the taxonomy code of 207VM0101X with a definition of:

Maternal & Fetal Medicine: An obstetrician/gynecologist who cares for, or provides consultation on, patients with complications of pregnancy. This specialist has advanced knowledge of the obstetrical, medical and surgical complications of pregnancy and their effect on both the mother and the fetus. The specialist also possesses expertise in the most current diagnostic and treatment modalities used in the care of patients with complicated pregnancies.

The same procedure is followed for both the individual/group of individuals and non-individuals. To see all of the taxonomy code choices, you can find them with this link to the NUCC web site: (http://www.nucc.org/index.php?option=com_wrapper&view=wrapper&Itemid=126)

Taxonomy Code Updates

The taxonomy code set is released and updated twice a year January 1^st and again on July 1^st of that year. Once the code set is released, there is a 90 day period before the code can be considered effective for use. This means that a code that is changed and released on January 1^st of that year, cannot be chosen/used until April 1^st of that year. The 90 day period between release and usage allows providers, vendors and payers time to make those specific changes into their respective data systems. It is interesting to note that the code description may not completely describe a specialty, so in some cases a provider might need to report more than one taxonomy code on their application for credentialing with payers. Again, a taxonomy code is chosen by the provider/entity itself, and is not chosen or assigned to the provider/entity by the 3^rd party payers. Using and choosing a closely matched taxonomy code will help expedite the timely processing of billing claims, and more accurately reflect the type of provider for the services that are rendered by your specialty. If possible, utilize the most definitive level 2 or level 3 taxonomy code. In some cases if the taxonomy codes does not “crosswalk” well with the NPI number, your claims could be delayed or denied by a payer.

Billing Claim Submissions:

There are different requirements when submitting taxonomy codes for electronic claims, UB04 institutional claims, and for CMS-1500 professional claims.

§ Electronic Claims: submissions with the ASC X12N 837P and 837I format are placed in segment PRV03 and loop 2000A for the billing level and segment PRV03 and loop 2420A for the rendering level

§ UB04 paper claims: The taxonomy code should be placed in box 81 and should be submitted with the “B3” qualifier

§ CMS-1500 paper claims: The taxonomy code should be identified with the qualifier “ZZ” in the shaded portion of box 24i. Then, the taxonomy code should be placed in the shaded portion of box 24j for the rendering level, and in box 33b preceded with the “ZZ” qualifier for the billing level.

As we continue to transition toward ICD-10 implementation currently set for October 1, 2015, it is important to make sure that the credentialing personnel for providers and facilities take a look at the taxonomy codes currently on file with the 3^rdparty payers and vendors that they do business with under HIPAA. The NUCC is adding more specific level 3 specialties when the updates are released again in July 2015, with implementation on October 1, 2015, and this coincides with the ICD-10 implementation. Best facility and provider based practices should review and update these codes when they are released to ensure clean claims and the most accurate data being submitted. In the long-run, this credentialing “housekeeping” provides a faster and correct revenue stream.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.comor you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

Finding clarity in coding of fetal status

Lori-Lynne A. Webb

February 27, 2015

The term “fetal distress” can be very misleading when coding for pregnancy related complications that involve the fetus. Unfortunately, in the OB/Gyn specialty the term “Fetal distress” is widely used, but is very misleading. The definition: of fetal distress in medical dictionaries note it as: “An abnormal condition of a fetus during gestation or at the time of delivery; marked by altered heart rate or rhythm and leading to compromised blood flow or changes in blood chemistry.” With this in mind, clarification of fetal diagnosis(es) or symptoms documented in the medical record by the provider is extremely important.

Medical providers even have a difficult time with the term “fetal distress”. The vagueness of the definition forces the providers to develop their own criteria rely on personal experience to decide if and when a fetus is in jeopardy. The AmericanCollege of Obstetricians and Gynecologists (ACOG) has weighed in on this issue, and suggests that physicians use the more descriptive "nonreassuring fetal heart rate tracing." However, many providers still use the term “fetal distress” rather than give a more definitive description of the fetal symptoms.

ICD-9 has not done coders any favors in their definition of fetal distress. (eg fetal metabolic academia) as shown below

656.31 Fetal distress affecting management of mother – Delivered

656.33 Fetal distress affecting management of mother – Antepartum

656.3X Excludes:

abnormal fetal acid-base balance (656.8x)

abnormality in fetal heart rate or rhythm (659.7x)

fetal bradycardia (659.7x)

fetal tachycardia (659.7x)

meconium in liquor (656.8x)

*note, codes in this category all require a 5^th digit for correct diagnosis reporting

ICD-10 does a better job in requiring specificity of the fetal symptom (antepartum maternal issue) than ICD-9 does. When looking at the cross references for the “fetal distress” ICD-10 leads the coder to the code section of O68. The example below shows the specificity of the abnormal fetal acid base balance, rather than just “fetal distress”. ICD-10 is much more specific when cross referencing the more specific abnormality in fetal heart rate or rhythm; as ICD-9 specifies it under code 659.7x.

O68 Labor and delivery complicated by abnormality of fetal acid-base balance

Fetal acidemia complicating labor and delivery

Fetal acidosis complicating labor and delivery

Fetal alkalosis complicating labor and delivery

Fetal metabolic acidemia complicating labor and delivery

Excludes1:

Fetal stress NOS (O77.9)

Labor and delivery complicated by electrocardiographic evidence of fetal stress (O77.8)

Labor and delivery complicated by ultrasonic evidence of fetal stress (O77.8)

Excludes2:

Abnormality in fetal heart rate or rhythm (O76)

Labor and delivery complicated by meconium in amniotic fluid (O77.0)

When it comes to finding a code for abnormal or non-reaassuring fetal heart rate (FHR) ICD-9 does present better choices of descriptive codes to work with. ICD-9 code 659.7X Abnormality in fetal heart rate or rhythm specifically states abnormality in the code description. Within code 659.7X, not only do we have the abnormality verbiage, but also verbiage such as Non-reassuring fetal heart rate, Fetal tachycardia, Fetal bradycardia and Fetal heart rate decelerations. Physicians and clinical providers can help coders by ensuring their clinical documentation includes clear descriptive and specific verbiage information in regard to fetal and maternal status.

In the list below, the following terms may be linked to abnormal or non-reassuring FHR’s.

o Nonreassuring FHR patterns

o Fetal tachycardia

o Fetal bradycardia

o Saltatory variability

o Variable decelerations associated with a non-reassuring pattern

o Late decelerations with preserved beat-to-beat variability

o Ominous patterns

o Persistent late decelerations with loss of beat-to-beat variability

As a coder, you may be challenged to understand what each of these terms mean, but if your provider is willing to document this information up-front, this makes the coding of fetal status much easier and more clearly identifiable. The fetal heart rate or FHR is normally determined via the Fetal Non-Stress Test (NST/FNST). A Fetal NST is a non-invasive test that can be performed by clinical personnel, then interpreted and the findings noted in the chart regarding the findings based on the heart-rate strip generated by a recording of the fetal heart rate over a period of a minimum 20 minutes. These strips that look similar to an EKG strip and their determination falls into 1 of 3 tiered categories.

Category I : Normal.

The fetal heart rate tracing shows ALL of the following:

Baseline FHR 110-160 BPM, moderate FHR variability, accelerations may be present or absent, no late or variable decelerations, may have early decelerations. May be considered a reactive fetal non-stress test

Strongly predictive of normal acid-base status at the time of observation. Routine care.

Category II : Indeterminate.

The fetal heart rate tracing shows ANY of the following:

Tachycardia, bradycardia without absent variability, minimal variability, absent variability without recurrent decelerations, marked variability, absence of accelerations after stimulation, recurrent variable decelerations with minimal or moderate variability, prolonged deceleration>2minutes but less than 10 minutes, recurrent late decelerations with moderate variability, variable decelerations with other characteristics such as slow return to baseline, and "overshoot".

Not predictive of abnormal fetal acid-base status, but requires continued surveillance and reevaluation.

Category III: Abnormal.

The fetal heart rate tracing shows EITHER of the following:

Sinusoidal patternORabsent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia.

Predictive of abnormal fetal-acid base status at the time of observation. Depending on the clinical situation, the provider of care should make efforts to emergently resolve the underlying cause of the abnormal fetal heart rate pattern.

In the documentation from the physician or provider, the notes should clearly state the category of the fetal status, and the diagnosis(es) to correlate with it. (eg tachycardia, bradycardia). ICD-9 gives us the codes of 659.7X. ICD-10 will cross reference into the codes O76 and 077.XX (see below)

O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery Depressed fetal heart rate tones complicating labor and delivery

Fetal bradycardia complicating labor and delivery

Fetal heart rate decelerations complicating labor and delivery

Fetal heart rate irregularity complicating labor and delivery

Fetal heart rate abnormal variability complicating labor and delivery

Fetal tachycardia complicating labor and delivery

Non-reassuring fetal heart rate or rhythm complicating labor and delivery

Excludes1: fetal stress NOS (O77.9)

labor and delivery complicated by electrocardiographic evidence of fetal stress (O77.8)

labor and delivery complicated by ultrasonic evidence of fetal stress (O77.8)

Excludes2: fetal metabolic acidemia (O68)

other fetal stress (O77.0-O77.1)

O77 Other fetal stress complicating labor and delivery

O77.0 Labor and delivery complicated by meconium in amniotic fluid

O77.1 Fetal stress in labor or delivery due to drug administration

O77.8 Labor and delivery complicated by other evidence of fetal stress

Labor and delivery complicated by electrocardiographic evidence of fetal stress

Labor and delivery complicated by ultrasonic evidence of fetal stress

Excludes1: abnormality of fetal acid-base balance (O68)

O77.9 Labor and delivery complicated by fetal stress, unspecified

Excludes1: abnormality of fetal acid-base balance (O68)

abnormality in fetal heart rate or rhythm (O76)

fetal metabolic acidemia (O68)

Now that we’ve explored the differences in what the diagnoses mean, and the ICD-9 and ICD-10 codes that correlate with it, let’s look at some documentation examples.

Example #1

Ms. L is a 38-year-old gravida 5, para 3, white female patient of Dr. Hero at 36-4/7 weeks' gestation who presents to the L&D ER complaining of uterine contractions.  They are anywhere from 4-10 minutes apart and are mild to moderate.  She denies any leaking fluid or ruptured membranes or bleeding.  She has had no problems with this pregnancy except that her blood pressure has been running somewhat high throughout her pregnancy with systolics in the 140s on numerous occasions and is correlated to gestational HBP.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Afebrile, vital signs stable. BP 141/79
GENERAL:  The patient is a well-developed, well-nourished, female in no acute distress.
ABDOMEN:  Soft.  Uterine contractions are present about every 4-6 minutes.
PELVIC:  Cervix is very posterior, -2 station, 50% and tight 2 cm, unchanged after walking for an hour.

Fetal heart tones show moderate variability, 15 x 15 accelerations and no decelerations with a baseline of 145.Category 1 FNST – no fetal stress noted.

ASSESSMENT:
False labor in an elderly multigravida/multiparous patient at 36-4/7 weeks' gestation with known pregnancy related HBP and reassuring with a category 1 FNST

PLAN:
Patient was given labor instructions. She will be calling Dr. Hero's office later in the day to get a refill on her Norco, Fioricet and labeletol. She does not want anything else from us now. Patient discharged in good condition from Emergency L&D.

ICD-9 Diagnoses:

644.03 Threatened premature labor prior to 37 weeks

659.63 Elderly multigravida, with antepartum condition or complication

642.33 Transient hypertension of pregnancy, antepartum

ICD-10 Diagnoses:

O60.03 Preterm labor without delivery, third trimester

O09.523 Supervision of elderly multigravida, third trimester

O13.3 Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester

The clinical rationale and medical necessity for performing the fetal non-stress test is due to the above diagnoses. We will not code any “fetal stress” as the testing was normal.

Example #2

Chief Complaint: Preterm Labor at 33 4/7 wks (inpatient setting)

Patient reports increased contractions this morning after an uneventful night. Contractions are once again resolving after Nubain. She received her 2nd BTMS dose this am at 0500. She denies leaking, bleeding or decreased fetal movement. She is on 2 gm/hr of magnesium and tolerating this better than the 3 gm/hr she had been on previously.

Afebrile. Normotensive. Lungs: CTAB CV:RRR

Abd: +BS. No guarding or rebound.

Pelvic: Cx 5/80/-3, slightly improved over yesterday.

Ext: No cords.

Fetal monitoring: Toco w irregular contractions. FHR baseline 130 with 15x15 accelerations, occasional decelerations and tachycardia with moderate variability, Category II non-stress test

Pt is a G3P0111 at 33 4/7 wks with advanced cervical dilation and preterm labor and fetal tachycardia.

Continue magnesium for tocolysis until 48 hours of BTMS and then discontinue. Continue to monitor fetus closely. Plan for possible preterm delivery in light of continued cervical change and dilation. NICU aware.

ICD-9 Diagnoses:

644.03 Threatened premature labor prior to 37 weeks

659.73 Abnormality in fetal heart rate or rhythm, antepartum condition or complication

ICD-10 Diagnoses:

O60.03 Preterm labor without delivery, third trimester

O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery

Rationale: Clear documentation of the threatened premature labor, and notation of a category II fetal non stress test that documents fetal tachycardia .

In conclusion, coders need to carefully review the clinical documentation for clear guidance of fetal diagnosis in relation to the visit, regardless if patient is inpatient status or outpatient status. If the documentation regarding fetal status is not readily apparent, then a query to the physician is necessary to determine the appropriate diagnosis for fetal status.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , CDIP, and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.

If any of you coders are looking for a new coding opportunity  Rocky Mountain Health &  Wellness is hiring for a coder/biller   it is in their Eagle office,     Full time position.. GOOD LUCK!!!  

Click here for more information 

or cut/past the address below.  

 http://www.indeed.com/viewjob?jk=6b0883de0b2d53f0&q=medical+coder&l=Idaho&tk=1aaqtp12v1q8reqt&from=ja&alid=993102929ed605e5&utm_source=jobseeker_emails&utm_medium=email&utm_campaign=job_alerts

** Thank you to ACOG and SMFM in regard to this issue:

ACOG, SMFM issue updated guidance on Zika

February 17, 2016

By Judith M. Orvos, ELS

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have released updated guidelines for clinicians caring for women of reproductive age amidst the Zika virus outbreak. The Practice Advisory, issued on February 12, replaces guidance in a similar document that was released on January 21.

Related: CDC guidelines for Zika virus

The advice to clinicians takes into consideration interim guidelines issued by the Centers for Disease Control and Prevention (CDC) on February 5. Regardless of whether a pregnant woman has clinical symptoms of Zika infection, if she has traveled to or lives in an endemic area, CDC, ACOG and SMFM now recommend that she undergo antibody testing. The organizations also are encouraging clinicians to provide counseling to women of reproductive age around the Zika virus that takes into consideration plans for pregnancy, including intentions and timing. Nonpregnant women who had or have had a confirmed infection with Zika virus should be reassured that there is no evidence that the infection increases risk of birth defects in subsequent pregnancies.

The complete practice advisory, including clinical algorithms for patient management and links to other resources on Zika infection, can be found at http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak. For perspective from Editor-in-Chief Charles J. Lockwood, visit http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/zika-virus-and-microcephaly

http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/acog-smfm-issue-updated-guidance-zika

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