Wednesday, August 31, 2011

New ICD-9 Codes for OB/GYN - ACOG

ACOG reports on the new ICD-9-CM Codes: Effective October 1, 2011

ACOG just posted that these are the codes that will be changing in the OB/GYN sections. If you want to view – please follow this link…

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, 2011. 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 code description for code 616 was revised to expand the categories of organisms. Prior to this change, the code description for code 616.10 (Vaginitis and vulvovaginitis, unspecified) included instructions for identifying the organisms, however, the code categories for the organisms now require a 5th digit assignment.

616 Inflammatory disease of cervix, vagina, and vulva
616.1 Vaginitis and vulvovaginitis
616.10 Vaginitis and vulvovaginitis, unspecified
Delete Use additional code to identify organism, such as
Escherichia coli [E. coli] (041.4), Staphylococcus (041.1), or
Streptococcus (041.0)

Add Use additional code to identify organism, such as:
Escherichia coli [E. coli] (041.41-041.49)
Staphylococcus (041.10-041.19)
Streptococcus (041.00-041.09)

Code 618 was revised to include a comment regarding reporting an additional code for any associated fecal incontinence.

618 Genital prolapse
618.0 Prolapse of vaginal walls without mention of uterine prolapse
618.04 Rectocele
Revise Use additional code for any associated
fecal incontinence (787.60-787.63)

Code 629 was expanded to include a new subcategory that provides coding instructions for reporting erosion and exposure of vaginal mesh. Previous coding advice was to assign code 996.76, (Other complications due to genitourinary device, implant, and graft) for the erosion and/or code 996.65, (Infection and inflammatory reaction due to other genitourinary device, implant and graft) if an infection occurred from the mesh.

629 Other disorders of female genital organs
subcategory 629.3 Complication of implanted vaginal mesh and
other prosthetic materials

New code 629.31 Erosion of implanted vaginal mesh and other
prosthetic materials to surrounding organ or tissue
Erosion of implanted vaginal mesh and other
prosthetic materials into pelvic floor muscles

New code 629.32 Exposure of implanted vaginal mesh and other
prosthetic materials into vagina
Exposure of vaginal mesh and other prosthetic
materials through vaginal wall

Code 631 has been expanded to address coding for what is referred to imprecisely as a false positive pregnancy, a chemical pregnancy, or a biochemical pregnancy. This would be reported in cases where a woman’s pregnancy test comes back as positive, indicating serum hCG levels, but when followed up with ultrasound, no fetus is present.

631 Other abnormal product of conception
Delete Blighted ovum
Delete Mole:
Delete NOS
Delete carneous
Delete fleshy
Delete stone

New code 631.0 Inappropriate change in quantitative human chorionic
gonadotropin (hCG) in early pregnancy
Biochemical pregnancy
Chemical pregnancy
Inappropriate level of quantitative human chorionic
gonadotropin (hCG) for gestational age in early pregnancy
Excludes: blighted ovum (631.8)
molar pregnancy (631.8)

New code 631.8 Other abnormal products of conception
Blighted ovum

The description of the exclusion term for code 632 was revised and updated to reference new code 631.8 (Other abnormal products of conception).

632 Missed abortion
Revise Excludes: that with abnormal product of conception (630, 631)
hydatidiform mole (630)

Add that with other abnormal products of conception (631.8)

Code 646.7 was revised to add biliary tract disorders to the code description.

646 Other complications of pregnancy, not elsewhere classified
Revise 646.7 Liver and biliary tract disorders in pregnancy

Hospitals and accreditation bodies are currently reviewing elective cesarean deliveries performed before 39 weeks gestation as a quality indicator. Code 649 was expanded to add a new subcategory, 649.8, to identify when onset of labor begins. Coding instructions include using an additional code to specify the reason for the planned c-section.

649 Other conditions or status of the mother complicating pregnancy,
childbirth, or the puerperium
NewSubcategory 649.8 Onset (spontaneous) of labor after 37 completed weeks of
[1-2] gestation but before 39 completed weeks gestation,
with delivery by (planned) cesarean section
Delivery by (planned) cesarean section occurring after 37
completed weeks of gestation but before 39 completed
weeks gestation due to (spontaneous) onset of labor

649.81 Onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section, delivered, with or without mention of antepartum condition

649.82 Onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section, delivered, with mention of postpartum condition
Use additional code to specify reason for planned cesarean section
such as:
cephalopelvic disproportion (normally formed fetus) (653.4)
previous cesarean delivery (654.2)

The title of the supplementary classification (V-codes) was revised to correctly report code series V91 as the final set of codes in this section. V91 codes were added to ICD-9-CM in October of 2010.


Code V12.2 was expanded to add codes for personal history of gestational diabetes and personal history of other endocrine, metabolic, and immunity disorders.

V12 Personal history of certain other diseases
V12.2 Personal history endocrine, metabolic, and immunity disorders

New code V12.21 Gestational diabetes

New code V12.29 Other endocrine, metabolic, and immunity disorders

Two codes were expanded in this code section. Code V23.4 was expanded to add coding for pregnancy (current) with history of ectopic pregnancy. Code V23.8 was expanded to add coding for pregnancy with inconclusive fetal viability.

V23 Supervision of high-risk pregnancy
V23.4 Pregnancy with other poor obstetric history
New code V23.42 Pregnancy with history of ectopic pregnancy

V23.8 Other high-risk pregnancy
New code V23.87 Pregnancy with inconclusive fetal viability
Encounter to determine fetal viability
of pregnancy


Changes to ICD-9-CM on October 1, 2011, represent the last regular annual update to the ICD-9 CM code set prior to the ICD-10 implementation in 2013. There will be limited ICD-9 and ICD-10 code updates in 2012 and 2013 to capture new technology and new diseases:

Oct 1, 2012 - limited code updates to both ICD-9 CM and ICD-10 code sets
Oct 1, 2013 - limited updates to ICD-10 code set
Oct 1, 2014 - regular updates to ICD-10 will begin, ending the freeze

Tuesday, August 30, 2011

Prolonged Services Office Based Coding

This is an article that was published in Physicians Practice on 08.30.2011 and reposted here with permission from the author - Betsy Nicoletti. This is some great information on the how-to's for prolonged services.

Prolonged Office Services
There are codes that can be used to bill for prolonged services; just be sure you understand that they are add-on codes
By Betsy Nicoletti | July 6, 2011


"I was in the exam room forever with that patient. Is there any way I can bill for that time?" Is there a clinician in the country who hasn't asked that question? And the answer usually involves someone — the clinician or staff member — searching through the CPT book.

There are CPT codes for prolonged services that a physician or non-physician practitioner (NPP) can report in addition to an evaluation and management (E&M) service for face-to-face time that is 30 minutes more than the typical time for that service. There are two sets of prolonged services codes that are paid by most insurers, including Medicare. These are 99354 and 99355 for office services, and 99356 and 99357 for facility services. This article discusses only office prolonged services. There are CPT codes for non-face-to-face services but they have a bundled status indicator in the Medicare Fee Schedule and are not reimbursed by Medicare or most payers.

The time must be the billing clinician's face-to-face time with the patient. Staff time doesn't count. The time a patient spends getting a nebulizer treatment while the clinician sees another patient doesn't count. Time that the physician spends on the phone outside the exam room coordinating care with the oncologist doesn't count. The time that matters is direct face-to-face time spent with the patient by the billing provider.

The prolonged services codes are add-on codes. That means, they may not be reported (that is, submitted on the claim form) alone. They must always be added on to another code. In this case, added on to specific E&M code and to only those companion codes listed in the CPT book after the descriptor for that code. These include new and established patient visits (99201-99215), office consultations, (99241-99245), Domiciliary, Rest Home, or Custodial Care services (99324-99328, 99334-99337) and Home Services codes (99341-99345, 99347-99350). Use prolonged services codes 99354 and 99355 only with these CPT codes.

One of the reasons that prolonged services are reported infrequently is because the threshold time to use the codes varies by each of the companion codes with which they can be used. The minimum time for reporting prolonged services is 30 minutes more than the typical time for the E&M code. Since the typical time for each of the E&M codes is different, the threshold time is different. Chapter 12 of the CMS Claims Processing Manual, Section 30.6.15 has a chart that shows the threshold time for using prolonged services with each level of E&M code. Download Chapter 12 of manual 100-04, found at

A common question is how to bill for an established visit that lasts 45 minutes. Should the clinician select 99215, (typical time 40 minutes) or should the clinician select 99213 (typical time 15 minutes) and 99354 (30 minutes of prolonged services)? For counseling visits, select the E&M service based on the total duration of the time, in this case, 99215. For services that are entirely counseling, only use prolonged services if the threshold time for the highest level of service in that category is met, plus the additional 30 minutes. However, if the visit consisted of an expanded problem focused history, an expanded problem focused exam, and low medical decision making ― which meet the criteria for a 99213 ― but the visit took 45 minutes to perform, bill 99213 and 99354.

The length of time spent must be medically necessary. CPT requires the total time of the visit to be documented. For Medicare patients, Medicare requires the start and stop time of the visit in order to report prolonged services. Clinicians can and should bill for prolonged services. Print out the chart from the Medicare Claims Processing Manual referenced above, and note the total time in the medical record for non-Medicare patients, and start and stop times for Medicare patients.

Betsy Nicoletti is the founder of She is the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at or 802 885 5641.

Monday, August 29, 2011

Tips to overcome maternity coding challenges for the inpatient coder

Tips to overcome maternity coding challenges for the inpatient coder

Maternity coding can be a challenge for inpatient coders Understanding what is comprised in obstetric/maternity care is critical to your success in coding and billing those services in the inpatient arena. Obstetric/maternity care is broken down into 3 separate areas
• Antepartum care
• Delivery of the baby(ies)
• Postpartum care

CPT has developed maternity codes that encompass services in a total obstetrical/maternity package, and allows the outpatient coder to bill for the antepartum, the delivery, and postpartum care in 1 CPT code. However, for the inpatient coder, you do not have that “luxury”. ICD-9 does not package those services into a single code set package.

Confusion about the codes is one of the first challenges that a coder has to face as an inpatient coder.
Maternity/obstetric care codes need to be broken down and analyzed as to which codes are appropriate for the services being rendered. Below are the basics for you to know

 What procedures and/or services is the hospital providing today?
 Appropriate diagnosis allocation (to include 4th and 5th digits)
 Auditing the services to ensure correct documentation by the provider to support the procedures billed by your facility

As a coder, when in doubt, always refer to your ICD-9 procedure’s (volume 3) to clarify guidelines and conventions of coding. In Chapter 13 (Obstetrical Procedures) of your ICD-9 Volume 3 Codes 72-75 , will provide you with all the majority of theprocedure codes you will need to bill obstetric/maternity code. , but in addition, you will need to be able to audit the physician documentation to accurately code these claims for your facility.

Codes set 72 includes a forcepts, vaccum and or breech delivery
Codes set 73 includes inductions and assistance procedures during delivery
Codes set 74 includes cesarean sections and the removal of a fetus
Codes set 75 includes other obstetric operations

In addition to the obstetrcal code sets, you also need to be familiar with the codes set from Chapter 12 which include the codes between 65 – 71), It is uncommon, but there are occasions when the obstetric/maternity patient has services provided that fall into the chapter 12 codes.

The key to coding and billing of obstetric/maternity related services, requires good, clear, documentation by the provider or physician, and a good understanding by the coder of what takes place during the maternity stay, to accurately code and bill for those services. The listed services below are normally included in obstetric/maternal services provided by the facility . This is not an all-inclusive list, but gives you an idea of what is involved.

Antepartum Services can include:
o Ultrasound(s)(Obstetric) radiologic services related to obstetrics
o Cerclage
o Insertion of a cervical dilator
o Echocardiography
o External cephalic version
o Fetal biophysical profile
o Administration of Rh immune globulin
o Amniocentesis
o Fetal Non-stress Test (NST)
o Blood Typing/and Rh factors and lab/pathology services related to maternity care
o Fetal non-stress testing
o Management and/or observation care of a chronic, stable illness such as pre-eclampsia, premature labor, diabetes, epilepsy, lupus erythematous or hypertension, Premature rupture of membranes etc//

Delivery Services can include:
 Admission to the hospital.
 Supervision and/or management of active labor, to include induction services.
 Vaginal, and Cesarean delivery.
 Delivery of placenta.
 Episiotomy.
 Fetal Services and monitoring (such as fetal EKG)
 Delivery of the placenta
 Repair of uterus, cervix or vagina during delivery

Postpartum care can include
 Procedures for post-delivery complications, such as hematoma, or obstetric hemorrhage status post delivery, or retained placenta
 services for sterilization
 symptoms and complications related to the pregnancy post delivery (i.e. seizures, diabetes, asthsma etc)

In addition to knowing what procedures you need to code for your facility, you also need to have a very good understanding of the diagnosis application to those procedures for maternity/obstetric patients. Again, if you are unsure, always refer to the coding conventions provided at the beginning of your ICD-9 manuals.
Below is a listing of common ob/maternity "complication" diagnoses. This “quick list” gives you an idea of diagnoses and symptoms you may want to be on the look-out for that may place your patient in a “risk” diagnosis area. You should always be on the look-out for diagnoses that have the CC (co-morbidity/complication) designation for your DRG grouper weights. :

– Pre-existing diabetes
– Gestational diabetes mellitus (GDM)
– Pregnancy-induced hypertension or pre-eclampsia
– Fetal anomaly or abnormal presentation (older than or equal to 36 weeks)
– Multiples (i.e. twins)
– Placenta previa
– Hypertension
– HIV (or abnormal screen)
– Prior preterm delivery
– Prior preterm labor requiring admission (e.g., early cervical change)
– Intrauterine fetal demise
– Prior cervical or uterine surgery
– Fetal anatomic abnormality
– Abnormal fetal growth
– Preterm labor requiring admission
– Abnormal amniotic fluid
– Bleeding
– Anemia
– Recurrent urinary tract infections or stones
– Advanced maternal age (35 yrs or older at EDC)
– Young maternal age (less than 16 yrs at EDC)
– Past complicated pregnancy

In coding and sequencing the diagnoses the 5th digit plays an important part of “telling the story” on your claim. ICD-9 Codes 640-649 and 651-676 require a 5th digit, and the list below denotes the “specific” episode of care. This 5th digit allows a vital understanding of whether or not the patient is in the antepartum, delivery, or postpartum phase of care.

– 0 – Unspecified (Rarely appropriate)
– 1 – Delivered with/without mention of antepartum condition
– 2 – Delivered with mention of postpartum complication
• Verify with supervisor before using these fifth digits in the outpatient clinic: 0-1-2
– 3 – Antepartum condition or complication
– 4 – Postpartum condition or complication

With Ob/Maternity services, sometimes the unexpected happens. You need to know how to code and bill services for miscarriage, ectopic tubal pregnancy, or an ectopic abdominal pregnancy. In these cases, the coder needs to bill the surgical intervention for the miscarriage or ectopic pregnancy. These procedure codes can be found in chapter 12, yet sometimes they are found in Chapter 13..

As you can see below two of the listed codes below are found in chapter 12, yet there are some that are reported from chapter 13.

o 66.62 Salpingectomy with removal of tubal pregnancy
o 69.02 Dilation and curettage following delivery or abortion
o 74.3 Removal of extratubal ectopic pregnancy

Another “big challenge” of OB/maternity coding is multiple gestations. In these cases, coders need to bill for multiple procedures based upon how many times performed, to directly correspond with the amount of babies that are delivered. ( i.e. 2 vaginal deliveries for twins.. Twin A and Twin B) These procedures CAN be different if Twin A is delivered via vaginal with a 72.4 code forceps rotation, and Twin B is delivered with code 72.71 as a vacuum extraction with an episiotomy.,

Last but not least … most hospital coding systems have a DRG grouper that is automated, but you should always check and know how to assign DRG's by hand.

To sum up the entire process for successful coding of inpatient obstetric/maternity care
 Understand and Know what encompasses maternity care
 Apply the correct procedure codes to the documentation from the provider/physician
 Apply the correct diagnosis codes to the procedures (and account for CC’s in your diagnosis application/allocation)
 Make sure you have the correct amount of “units” (in the case of multiple gestations)
 Double check your DRG groups/grouper that the services are weighted correctly and are grouped In the correct DRG codeset.