Pelvic Congestion Syndrome: Pelvic Varices

5/13/2018

Pelvic congestion syndrome is denoted as chronic pelvic pain in women who have varicose veins in or near their ovaries within the pelvic cavity.  Pelvic congestion syndrome is a common cause of chronic pelvic pain, but many times is overlooked as a cause for the pelvic pain.  In women that have pelvic varicose veins and venous insufficiency pelvic pain is a complaint, however, may not have any symptoms at all.  It remains a medical mystery as to why some women develop pain and other symptoms, yet others have no complaint at all.  The majority of women diagnosed with pelvic congestion syndrome normally fall within the 20-45 year age demographic and have had multiple pregnancies.

Physician have noted that chronic and acute pelvic pain from these enlarged veins,  primarily develops after pregnancy, and the pain level from this trends upward and seems to worsen with each subsequent pregnancy.  Typically, this type of pelvic pain is a dull ache, however, it may be reported by the patient as an acute, sharp, stabbing, or throbbing type of pain.   Some patients have stated that it seems to worsen at the end of the day, or after sitting/ standing for long periods of time.  Pelvic pain from pelvic varices can also occur during or after sexual intercourse, and may be accompanied by low back pain, aches in the legs, and abnormal menstrual bleeding.   In addition, some women may also have varicose veins in the vulva, vagina, perineal area, buttocks, thighs, and lower legs.  And as if these symptoms weren’t enough, some women experience a clear or watery discharge from the vagina, fatigue, mood swings, headaches, abdominal bloating, painful ovaries and cervical pain with motion tenderness.

Diagnosing Pelvic Congestion Syndrome

In the clinical diagnosis and documentation of pelvic congestion syndrome, a diagnosis can be made using non-invasive ultrasound testing, or by a diagnostic pelvic laparoscopy.  Ultrasound is the diagnostic tool most commonly used and many OB physicians perform both an abdominal and a transvaginal duplex ultrasound in the office as the first-line testing .  These ultrasounds may be enough to enable the provider to see if there is a pelvic varicosity within the pelvic area, and if venous enlargement and/or venous reflux is causing the patients’ pelvic pain.   Unfortunately ultrasound may not show pelvic varices, or pelvic veins well, especially when the patient is lying down, or is obese.  Ultrasound does not produce good images in patients that are obese as the sound waves do not travel through adipose tissue as well as they do in non-obese patients.  

If ultrasound does not diagnose or confirm the pelvic congestion syndrome, additional testing such as venography, CT, MRI, magnetic resonance venography may be necessary to confirm the pelvic varicosities diagnosis.  If venography is performed, contrast dye tests may be utilized for better imaging and real time viewing.  If non-invasive procedures do not give the provider a good confirmed diagnosis of pelvic congestion syndrome, then the option of a diagnostic surgical pelvic laparoscopy may be the next choice for diagnosis confirmation. 

When Pelvic Congestion Syndrome occurs pelvic pain is one of the first symptoms, however, clinically,  the same effect happen to the pelvic veins , similar to development of varicose veins that develop in other areas of the body, such as in the perineal, vulvar and groin area, and the upper and/or lower extremities.  The physiology behind this, is the vein valves in the veins no longer function normally, causing blood to back up within the vein, therefore becoming enlarged,  engorged or “congested”.  This “congestion” is what causes the pain.

Treatment for pelvic congestion syndrome

OB providers may treat pelvic congestion syndrome with oral drug therapy, such as NSAIDS (nonsteroidal anti-inflammatory drugs) which can reduce pain, decrease fever, prevent blood clots and, reduce inflammation.  At this time, aspirin, ibuprofen, and naproxen sodium, can be purchased over the counter, but many NSAIDs, such as ketorolac tromethamine, celecoxib, meloxicam and many others still requires a prescription from the provider.  Usually  the first line treatment is nonsteroidal anti-inflammatory drugs, as nonsteroidal anti-inflammatory drugs (NSAIDs) usually relieve the pain.  If NSAIDs are ineffective, the provider may prescribe a suppression of ovarian function and prescribe oral or injected hormone therapy.  It is also becoming more and more common for providers to refer patients out for non-traditional medical therapies for pain relief such as acupuncture therapy, physical therapy, bio-feedback training, and yoga meditative therapy in addition to traditional medical therapy. 

 

If the above treatments fail, the next option is a minimally invasive surgical option which involves stopping blood flow to the varicose veins using  a procedure called known as venous embolization. The procedure requires an overnight stay in hospital, and is done using a local anesthetic or conscious sedation, and has a fairly high success rate.

Currently there are two procedures are available:

·         Embolization of a vein: After using an anesthetic to numb a small area of the thigh, doctors make a small incision there. Then, they insert a thin, flexible tube (catheter) through the incision into a vein and thread it to the varicose veins. They insert tiny coils, sponges, or glue-like liquids through the catheter into the veins to block them.

·         Sclerotherapy: Similar to embolization, a catheter is inserted into the vein, and the provider injects a sclerosing solution through it and into the varicose veins. The solution blocks the vein(s).  It is assumed that when blood can no longer flow into the varicose vein(s) in the pelvis, the pain usually lessens.

Coding Considerations:

Scenario 1 - For pelvic congestion syndrome

A diagnostic venogram is obtained from a right common femoral venous puncture, with selective catheterization and diagnostic venography of the left renal vein, left ovarian vein, bilateral hypogastric veins, and bilateral external iliac veins. A large, varicose left ovarian vein is shown with reflux into enlarged uterine veins. The left ovarian vein is embolized with coils and sotradecyl.

CPT Codes:

·         37241: Venous embolization

·         36012X3: Selection of left renal/ovarian, left hypogastric, left external iliac veins

·         36011: Selection of right hypogastric vein

·         75822-59: Bilateral extremity venogram

·         75831-59: Left renal/ovarian venogram

ICD-10cm Codes

·         N94.89 Other specified conditions associated with female genital organs and menstrual cycle

·         I86.2 Pelvic varices

·         R10.2 Pelvic and perineal pain

Scenario 2 - Pelvic congestion syndrome, persistent unimproved pelvic pain despite bilateral gonadal vein embolizations

Moderate sedation was employed using Versed and Fentanyl titrated for patient comfort by a trained independent observer. Continuous physiologic monitoring vital signs was performed for approximately 105 minutes.

Lidocaine was administered locally. A small dermatotomy was made and a micropuncture needle was placed into the right internal jugular vein. Ultrasound guidance was used. A hardcopy image was saved. An 0.018" wire was easily passed. A micropuncture sheath assembly was advanced and a Benson guidewire was then advanced into the IVC.

A 6 French sidearm sheath was then placed into the IVC.

Using AP venous catheter, the right internal iliac vein was catheterized contrast was injected to confirm position. The catheter was then advanced over a wire into the main trunk draining pelvic varicosities. A 1 cc Foley catheter was then advanced over an exchange length Bentson guidewire and the balloon was insufflated proximally 0.3 cc of dilute contrast to include flow. Approximately 5 cc of contrast was then gently injected to fill numerous large pelvic varicosities. Access was then gained into the left internal iliac vein and contrast was injected. A 1 cc Fogarty catheter was then placed into the left internal iliac vein and contrast was injected following insufflation of the balloon. Access was regained into the right internal iliac vein varicosity. The portable gland was insufflated to occlude flow and 3 cc of 3% Sotradecol was then administered as a sclerosing agent. This was allowed to dwell for 5 minutes. Repeat venogram was performed which demonstrated decreased size of varicosities.  The catheter was removed and manual compression was used to achieve hemostasis.

FINDINGS:

1.    Initial right internal iliac vein venogram demonstrates numerous large varicosities in the pelvis. The majority of these are present inferiorly. Treatment was performed only of the more inferior varicosities. Post sclerotherapy venogram demonstrates significant decrease in size of varicosities.

2.    Left internal iliac vein venogram demonstrates several mildly enlarged pelvic veins. These are much less impressive than noted on the right.

CPT Codes:

·         36470 Injection of sclerosing solution; single vein

·         75822 Venography, extremity, bilateral, radiological supervision and interpretation

·         36012 (rt int iliac) Selective catheter placement, venous system; second order, or more selective, branch (e.g., left adrenal vein, petrosal sinus)

·         36012 (lt int iliac) Selective catheter placement, venous system; second order, or more selective, branch (e.g., left adrenal vein, petrosal sinus)

ICD-10cm Codes

·         N94.89 Other specified conditions associated with female genital organs and menstrual cycle

·         I86.2 Pelvic varices

·         R10.2 Pelvic and perineal pain

Billing/Reimbursement Issues

Some 3^rd party payers may consider venous embolization or pelvic venous sclerotherapy of the ovarian or internal iliac veins as experimental, unproven or not medically necessary.  If the provider and patient wish to have this procedure performed, a pre-authorization and patient/insurance policy review should be performed before the procedure is scheduled.   If the insurance carrier does not consider these procedures as medically valid, or necessary be sure to have the patient sign an advanced beneficiary notice and collect payment as appropriate for your practice.

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/.  

Usage of Time Based Billing for CPT  Evaluation and Management

Lori-Lynne A. Webb

07.21. 2018

Within the guidelines of the CPT code book, CPT  has stated;  “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.  This includes time spent spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (eg, foster parents, person in loco parentis, legal guardian).  The extent of counseling and/or coordination of care must be documented in the medical record.”

What this means to our physicians and providers, is that time alone can be used to select a level of care, and bill for our services regardless of the clinical documentation of history, exam and medical decision making that is noted or documented in the in the medical record for the current encounter or visit. 

The lack of complete documentation from busy providers is an area of concern that many coders see and take note of when performing coding audits in their role as a coder/clinical documentation specialist. Physicians are not consistently documenting the “nuts and bolts” of the core CPT criteria needed in regard to meet the CPT’s criteria especially when admitting their patients to the hospital.   

The CPT codes 99221 – 99223 are set aside for inpatient admission, and the lowest level admission code, 99221(level 1 admit)  requires a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of straightforward or low complexity;  the 99222 (level II admit)  requires a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity, the 99223 (level III admit)  requires a comprehensive history; a comprehensive examination; and medical decision making of high complexity.  Also within meeting these criteria, all three key components are to be met.  The only difference between a 99222 and a 99223 code is the medical decision making of moderate complexity vs/ high complexity.

As a case in point, In order to bill a 99222  “level II” admission, CPT guidelines require a comprehensive exam to be noted in the clinical documentation of the medical record. 

It is common to see the clinical documentation noted in the record denoting a  comprehensive history, and moderate to high level medical decision making, but the “exam” portion can be very  skimpy. 

As per the 1995 exam guidelines to code/bill a 99222 or a 99223 admission, the clinical documentation must state that greater than 8 body systems or body areas were examined to meet the comprehensive exam requirement (on a multisystem exam).  

As per the 1997 exam guidelines the clinical documentation must state that for the Comprehensive Examination (single specialty)  – should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected.

Unfortunately, the reality is that these examinations are more than likely being performed by the providers, however, coders are finding that clinicians are doing a  poor job of documenting that these exams were performed, even with the many EMR documentation tools at their disposal. 

 However, if these physicians and providers utilize the option of documentation of “Time” in the clinical notes,  they still have to document the care given, but it can be noted that they spent “XX amount of time”  at the bedside and/or on the unit in care of the patient and of that 50% of this time was spent in counseling, and coordination of care of “XXX diagnosis, testing, etc”

From a revenue and denial standpoint, it is frustrating to have an auditor or insurance carrier review the clinical chart and downcode the admission from a  99222/223 to a low level admission 99221 due to skimpy history,  exam, or medical decision notations. 

So the “pearl” of wisdom is to be cognizant of the clinical documentation habits, for the physician providers, which can include macro’s, shortcuts and additional EMR/EHR data based tools.  As coders/billers/managers,  we need to be diligent and educate providers on the usage of time based billing for admissions and other pertinent E&M services. 

Not all CPT E&M services have a time based component that can be utilized to represent the care provided.  Within the CPT codes outlined for usage in an Emergency Department, “Time” is NOT a descriptive component, and all three key components for each CPT code 99281 - 99285 must be denoted within the emergency department patient visit.    The rationale that CPT gives us for this caveat is that emergency services that are typically provided can be hugely variable due to acuity and presenting diagnosis factors. 

The usage of time should not be a totally foreign concept to most providers, as this has been in place in one form or another since1992.  The usage of time as a billing/coding component for providers to use, can get overlooked, or forgotten when in the heat of the moment, or in the day to day busy patient load or high complexity patient demand on the provider.  

Time based clinical documentation does need to be very specific,  The face-to-face time spent in an outpatient or office type setting  includes not only the time the provider spent counseling and coordination of the patients care but has to be rendered face to face with the patient.   Any pre or post time spent ( when patient and provider are not face to face) cannot be included in the time component described in the CPT E&M codes. 

If the provider is providing care for a patient that is on a hospital unit or floor, the intraservice time for these codes is noted or defined as “unit/floor time”  which includes the time present on the patient’s hospital unit and at the patient’s bedside providing services for that patient.   In this setting, this includes time to establish and review the patient’s chart, examine the patient, write clinical notes, documentations,  orders and to communicate with other providers and the patient’s family.   In this hospital setting the pre and post time including time spent off that patient’s floor are NOT to be included in the time component noted in the CPT code descriptors. 

In the descriptors below it outlines the criteria for the 99221, 99222 and 99223 hospital admission codes and how the dime designations are presented.   These times noted in the CPT descriptions are considered a “typical” amount of time spent, however, actual time may vary.

CPT® 99221 is defined by the AMA as:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of straightforward or low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit.

CPT® 99222 is defined by the AMA as:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.

CPT® 99222 is defined by the AMA as

Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit.

Clinical documentation of time can be denoted as a cumulative amount, or as a time in/time out notation within the record.  In a best practice, the provider would document both.  

Appropriate time statement examples

·         Time in was 1400,  time out at 1506, I spent 40 minutes of the 66 minutes in the encounter counseling the patient on  their diagnosis  of  “xxxxx” and the remainder of the time was spent obtaining the HPI and examination of the patient.

·         I spent greater than 50% of my 30 minute visit with the patient discussing the options of surgery versus watchful waiting regarding their diagnosis of “xxxxxx”

Inappropriate Time Statement Examples:

·         I had a lengthy discussion with the patient.

·         I spent 20 minutes in supportive counseling.

·         I spent 15 minutes talking about the treatment options.

·         I spent 30 minutes with the patient

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/.  

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