Thursday, September 2, 2010

ACOG speaks again: Reporting the Confirmation of Pregnancy Visit

From our friends @ ACOG: Enjoy!

Reporting the Confirmation of 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.

Here is an example to help clarify the issue:
If a patient presents with signs or symptoms of pregnancy or has had a positive home pregnancy test and is there to confirm pregnancy, this visit may be reported with the appropriate level E/M services code. However, if the OB record is initiated at this visit, then the visit becomes part of the global OB package and is not billed separately.

If the pregnancy has been confirmed by another physician, you would not bill a confirmation of pregnancy visit.

The confirmation of pregnancy visit is typically a minimal visit that may not involve face to face contact with the physician (for an established patient). The physician may draw blood and prescribe prenatal vitamins during this initial visit and still report it as a separate E/M service as long as the OB record is not started.

Diagnostic Reporting Options:
V72.40 Pregnancy examination or test, pregnancy unconfirmed
V72.41 Pregnancy examination or test, negative result
V72.42 Pregnancy examination or test, positive result

The physician should report V72.40 if the encounter is to test for a suspected pregnancy and the patient leaves without knowing the results. If the pregnancy test is negative, report code V72.41. Report code V72.42 if the pregnancy is confirmed but the obstetrical record is not initiated. This diagnosis code is also used when the physician sees the patient for the confirmation of pregnancy but will not be providing the global obstetric care.

Global obstetrical care begins when the obstetrical record is initiated as part of the physician's comprehensive obstetrics work-up which includes the comprehensive history and physical.

Note that some payers may now view an initial obstetrical ultrasound performed in the office at the initial visit, as part of the comprehensive work up that initiates the global package. If this service is performed, your specific payer may view the initial visit as included in the global OB package even if the visit is reported with an E/M service code.

As not all payers follow CPT guidelines as to the contents of the global obstetrics package, you should always check with your specific payers for their definition of the global obstetrics package. Be sure to keep a written copy of any instructions.

A final point to keep in mind is that not every initial OB visit will be reportable outside of the global package. Deciding when to initiate the global OB care depends on the clinical circumstances, the physicians’ medical judgment, and payer reimbursement policies.

Questions/comments may be sent to ACOG's Coding Staff via email at

OB/GYN - New ICD-9-CM Codes: Effective October 1, 2010

Straight from the ACOG website...

These codes will be of interest to you if you code/bill any OB or GYN services...

New ICD-9-CM Codes: Effective October 1, 2010

Following are the new, expanded, and revised ICD-9-CM codes that are of interest to obstetricians and gynecologists. These codes will take effect October 1, 2010. HIPAA requires providers to use the medical code set that is valid at the time the service is provided. Therefore, physicians must cease using discontinued codes for services after the new codes become effective October 1.

The term “habitual aborter” was used within the descriptions of codes 629.81 and 646.3 for patients with recurrent pregnancy loss. Due to confusion over the use of these codes and patient sensitivity to being referred to as a habitual aborter, the American Congress of Obstetricians and Gynecologists (ACOG) requested the codes be revised to state “recurrent pregnancy loss”... The term “habitual aborter” will still appear in the ICD-9-CM index under code 621 (Disorders of Uterus, Not Elsewhere Classified).

629.8 Other specified disorders of female genital organs
629.81 Habitual aborter Recurrent pregnancy loss without current pregnancy
Excludes: habitual aborter Recurrent pregnancy loss with current pregnancy (646.3)

646 Other complications of pregnancy, not elsewhere classified
646.3 Habitual aborter Recurrent pregnancy loss

Müllerian anomalies include all congenital anomalies of the uterus, cervix and vagina. Congenital uterine anomalies are classified into seven distinct types: agenesis, unicornuate, didelphus, bicornuate, septate, arcuate, and diethylstilbestrol (DES) related anomalies. Of these, only didelphus and DES related anomalies previously had unique ICD-9-CM codes; 752.2 and 760.76, respectively.

Vaginal and cervical anomalies are less common. Prior to this change, there were unique codes only for imperforate hymen (752.42) and embryonic cyst of cervix, vagina, and external female genitalia (752.41).

752 Congenital anomalies of genital organs
752.3 Other anomalies of uterus
752.31 Agenesis of uterus
Congenital absence of uterus
752.32 Hypoplasia of uterus
752.33 Unicornuate uterus
Unicornate uterus with or without a separate uterine horn
Uterus with only one functioning horn
752.34 Bicornuate uterus
Bicornuate uterus, complete or partial
752.35 Septate uterus
Septate uterus, complete or partial
752.36 Arcuate uterus
752.39 Other anomalies of uterus
Aplasia of uterus NOS
Müllerian anomaly of the uterus, NEC
752.4 Anomalies of cervix, vagina, and external female genitalia
752.43 Cervical agenesis
Cervical hypoplasia
752.44 Cervical duplication
752.45 Vaginal agenesis
Agenesis of vagina, total or partial
752.46 Transverse vaginal septum
752.47 Longitudinal vaginal septum
Longitudinal vaginal septum with or without obstruction
752.49 Other anomalies of cervix, vagina, and external female genitalia
Absence of cervix, clitoris, vagina, or vulva
Agenesis of cervix, clitoris, vagina, or vulva
Anomalies of cervix, NEC
Anomalies of hymen, NEC
Müllerian anomalies of the cervix and vagina, NEC

The fecal incontinence code (787.6) has been expanded to allow for the classification of symptoms such as: fecal smearing, fecal urgency and incomplete defecation.

787 Symptoms involving digestive system
787.6 Incontinence of feces
Encopresis NOS
Incontinence of sphincter ani
787.60 Full incontinence of feces
Fecal incontinence NOS
787.61 Incomplete defecation
787.62 Fecal smearing
Fecal soiling
787.63 Fecal urgency

Additionally, a unique code for fecal impaction was created with appropriate instructional notes that distinguish the new symptom codes within the 787.6 series from the codes for fecal impaction and constipation.

560.32 Fecal impaction


To clarify the difference between long term and prophylactic use of medications, many revisions have been made to the tabular and index sections of ICD-9-CM. Changes include revisions to the title of category V07 (Need for isolation and other prophylactic measures) and titles for the codes under subcategory V07.5 (Prophylactic use of agents affecting estrogen receptors and estrogen levels), in addition to revisions to the index entries for prophylactic use of antibiotics.

V07 Need for isolation and other prophylactic or treatment measures
Excludes: long-term (current) (prophylactic) use of certain specific drugs (V58.61-V58.69)
V07.5 Prophylactic uUse of agents affecting estrogen receptors and estrogen levels
V07.51 ProphylacticuUse of selective estrogen receptor modulators (SERMs)
V07.52 Prophylactic uUse of aromatase inhibitors
V07.59 Prophylactic uUse of other agents affecting estrogen receptors and estrogen levels

New codes have been established for personal history of vaginal and vulvar dysplasia. These codes explain the reason for the encounters and parallel the existing code for personal history of cervical dysplasia (V13.22).

V13.23 Personal history of vaginal dysplasia
V13.24 Personal history of vulvar dysplasia

When congenital conditions are corrected, coding guidelines state that “a personal history code should be used to identify the history of the anomaly.” Code series V13.6 has been expanded and additional codes have been added to identify personal history of congenital anomalies by body system.

V13.6 Congenital (corrected) malformations
V13.62 Personal history of other (corrected) congenital malformations of genitourinary system
V13.69 Personal history of other (corrected) congenital malformations

Code V25.1 has been expanded to include both insertion and removal of an IUD. Use of code V25.42 will now be limited to routine surveillance of an existing device. New codes V25.12 and V25.13 can be reported with code V25.42 on a record.

V25.1 Encounter for insertion or removal of intrauterine contraceptive device
Excludes: encounter for routine checking of intrauterine contraceptive device (V25.42)
V25.11 Encounter for insertion of intrauterine contraceptive device
V25.12 Encounter for removal of intrauterine contraceptive device
V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device
Encounter for replacement of intrauterine contraceptive device
V25.42 Intrauterine contraceptive device
Checking, reinsertion, or removal of intrauterine device
Excludes: insertion or removal of intrauterine contraceptive device (V25.11–V25.13)
of intrauterine contraceptive device as incidental finding (V45.5)

The body mass index (BMI) code section has been expanded and additional codes have been added to allow for specificity of BMI over 50. The new codes will allow for tracking patients at increased health and surgical risk.

V85.42 Body Mass Index 45.0-49.9, adult
V85.43 Body Mass Index 50.0-59.9, adult
V85.44 Body Mass Index 60.0-69.9, adult
V85.45 Body Mass Index 70 and over, adult

A new V code category was developed to allow delineation of placenta status when reporting multiple gestations. The new codes indicate the number of placentas and amniotic sacs.

V91 Multiple gestation placenta status
Code first multiple gestation (651.0-651.9)
V91.0 Twin gestation placenta status
V91.00 Twin gestation, unspecified number of placenta, unspecified number of amniotic sacs
V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)
V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)
V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)
V91.09 Twin gestation, unable to determine number of placenta and number of amniotic sacs
V91.1 Triplet gestation placenta status
V91.10 Triplet gestation, unspecified number of placenta and unspecified number of amniotic sacs
V91.11 Triplet gestation, with two or more monochorionic fetuses
V91.12 Triplet gestation, with two or more monoamniotic fetuses
V91.19 Triplet gestation, unable to determine number of placenta and number of amniotic sacs
V91.2 Quadruplet gestation placenta status
V91.20 Quadruplet gestation, unspecified number of placenta and unspecified number of amniotic sacs
V91.21 Quadruplet gestation, with two or more monochorionic fetuses
V91.22 Quadruplet gestation, with two or more monoamniotic fetuses
V91.29 Quadruplet gestation, unable to determine number of placenta and number of amniotic sacs
V91.9 Other specified multiple gestation placenta status
Placenta status for multiple gestations greater than quadruplets
V91.90 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs
V91.91 Other specified multiple gestation, with two or more monochorionic fetuses
V91.92 Other specified multiple gestation, with two or more monoamniotic fetuses
V91.99 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs

Sunday, August 29, 2010

Coding for Smoking Cessation - Info straight from CMS!

Coding Information for SMOKING CESSATION… Info Straight from CMS

Hi to my blog readers... This is just another reminder that CMS now pays for smoking cessation, and that they are committed to helping our patients quit smoking. In addition, these services are billable, (and payable from Medicare) with proper documentation. Please be sure that your providers denote this as "separately identifiable" from your regular E&M visits AND have your time documented of the minutes spent in the smoking/tobacco cessation counseling visit. (time-in/time-out is the best for audit substantiation, but a notation of how much time spent is OK too.)

I've included some websites where this info can be found at the end of the blog.
  • 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes
  • 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
  • Diagnosis code 305.1

CMS smoking cessation guidelines & information:

Smoking is the most preventable cause of disease and death in the U.S. People who continue to smoke after the age of 65 have a higher overall risk of disease and death than those who quit. Smoking contributes to and can exacerbate heart disease, cancer, stroke, lung disease, hypertension, diabetes, osteoporosis, macular degeneration, and cataracts. It can also interfere with the effectiveness of medications that many older adults take, including insulin.

In March 2005, CMS determined that there was sufficient evidence to support Medicare coverage for smoking and tobacco use cessation counseling for beneficiaries who have smoking-related illnesses, or who are taking medications that are affected by tobacco use. Medicare's prescription drug benefit will also cover smoking cessation treatments prescribed by a physician beginning in January 2006.

This section provides information regarding Medicare's smoking and tobacco use cessation counseling benefit, resources to support providers in the delivery of counseling, and organizations promoting cessation to older adults.

General Facts:

• An estimated 9.3% of people ages 65 and older smoke cigarettes.

• Approximately 440,000 people die annually from smoking related diseases, and 300,000 of those deaths occur in people ages 65 and older.

• One study estimated that Medicare spends about 10% of its total annual budget on treating smoking-related illnesses--approximately $24 billion in 2001.

• There are significant benefits to quitting smoking, even after 30 or more years of smoking. Lung function and circulation begin to improve soon after quitting. Smokers who quit have cardiovascular mortality rates similar to those of non-smokers, and this benefit is unrelated to age or the time elapsed since quitting. In one study, older smokers who already had coronary artery disease improved their survival and risk of heart attack by quitting.

• Older adults who smoke have been shown to be more successful at quitting than younger smokers.

What Medicare covers:

Medicare covers 2 types of counseling:

• Intermediate cessation counseling is 3 to 10 minutes per session; and

• Intensive cessation counseling is greater than 10 minutes per session.

Medicare will cover 2 quit attempts per year. Each quit attempt may include a maximum of 4 intermediate or intensive counseling sessions, with the total annual benefit covering up to 8 sessions in a 12-month period. The health care provider and patient have the flexibility to choose between intermediate and intensive counseling.

To be eligible to receive this benefit, a beneficiary must have a condition that is adversely affected by smoking or tobacco use, or that the metabolism or dosing of a medication that is being used to treat a condition the beneficiary has is being adversely affected by his or her smoking or tobacco use.

In addition, Medicare Part D will also cover smoking cessation treatments prescribed by a physician beginning in January 2006. However, over-the-counter treatments, such as nicotine patches or gum, will not be covered.

Other helpful information:

In addition to Medicare's smoking cessation counseling benefit, the Department of Health and Human Services launched a national telephone counseling quit line for all smokers in the U.S. The toll free number 1-800-QUITNOW (1-800-784-8669, TTY 1-800-332-8615) is a single access point to the National Network of Tobacco Cessation Quit lines. Callers are routed to a state-run quit line for assistance. If there is no state-run quit line, they are routed to the National Cancer Institute's quit line.

"Coder in Residence" Asset to the practice!

Welcome back to the blog ...

This week I found a great article that was written by Judy Capko. It was originally published in Physician Practice Pearls.

Heartfelt thanks to Judy, for allowing me to share! Please check out Judy's blog


Coder in Residence

By Judy Capko

The benefit of having your own in-house billers is that they are well-versed in billing procedures for your practice and specialty. They will come to learn your physicians’ coding patterns and preferences.

However, if your practice is small, the downside means requiring your billing department to be the proverbial “jack of all trades.” Sometimes this arrangement is less than practical. Understandably, their first priorities are getting your daily services recorded and generating claims as quickly as possible. In between they will be busy trying to get your claims paid, collecting patient deductibles and copays, and handling whatever else comes their way.

So, how is this complex function orchestrated in your practice? Do you just cross your fingers and hope for the best? Or, do you have a reliable coding/billing manager who has her finger on the pulse of your practice? Whatever the size of your practice, you need to designate a key person to direct the flow of your billing department, if you have one.

I like to call this person a “coder in residence.” A coder in residence is of chief importance to the success of your practice, so you need to select the right person for the job. Obviously that person should have up-to-date coding knowledge, but also should be willing to take responsibility — which means being accountable for results.

Here are the primary responsibilities for a coder in residence:

1. Ensures that coding accurately represents the services performed and that services are coded appropriately so that claims will be paid correctly the first time.

2. Monitors/audits the coding and billing performance of your practice at routine intervals.

3. Makes sure that coders are using the most up-to-date CPT and HCPCS coding manuals and stays current with the most recent changes in ICD-9/10 diagnostic coding.

4. Obtains coding continuing education courses each year with close attention to changes specific to the practice.

5. Presents an annual coding update for the entire practice that focuses on coding procedural changes.

6. Provides formal coding training for all new hires, both providers and billing staff, within 30 days of hire.

Your coder in residence should also monitor the coding performance and variances for all providers each month by graphically comparing each provider and presenting the results and analysis to the management team. In other words, is there a reasonable explanation why one physician is producing more low-level E&M services while another physician in the same practice is coding mostly level 4s and 5s? It may be reasonable if the first physician sees more patients with routine problems, while the other manages patients with multiple chronic problems.

Should your coder be certified? I think it’s a good idea. After all, your coder is at the center of a process that drives the revenue flow for your practice. The American Academy of Professional Coders offers certification for coders. Once certified, coders are required to obtain continuing education credits to maintain their certification.

Your practice can only get paid when your coders correctly code and submit claims to payers. With a typical physician generating a minimum of $400,000 in billable claims annually, it would be foolish to skimp on your coding/billing staff. A well-trained and managed coding staff can help the entire practice bring in every dollar it earns. Give them the support they deserve. It’s a prudent investment in your practice’s future.

Judy Capko is a healthcare consultant and author of the popular books “Secrets of the Best Run Practices” and “Take Back Time.” Based in Thousand Oaks, Calif., she is a national speaker on healthcare topics. She can be reached at or 805 499 9203. You can also check out Judy’s blog at

This article originally appeared in the July/August 2010 issue of Physicians Practice.