Documentation; Diagnoses and CPT: difficult choices…….

Originally posted by Justcoding.com as written by me...    Enjoy! 

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Documentation; Diagnoses and CPT:  difficult choices…….

August 11, 2016

Coding in the outpatient realm can be a challenge.  One of the areas that coders struggle with is when there are two or more choices for similar procedures.  This creates a dilemma for the coder, as the documentation and diagnoses attached to those codes can mean a huge difference to the practice, or physician in terms of reimbursement based upon the RVU values.  In some instances, this could also mean that the choices presented in CPT may not be well represented, and the coder is then faced with the decision to go with a code that is "close", or do they choose an "unlisted" code, then have to figure out how to "price" it for payment and still get the provider/physician good reimbursement.   However, when coding with the ICD-10pcs for hospital services, it is much more clear-cut and straightforward, than those codes for physician based services that are coded from CPT.

Within the CPT code-set there are many options to code from especially when it comes to codes and procedures that can be used from the integumentary system and/or from one of the specialty organ system chapters.  Outlined below, some of the codes in the integumentary section of the CPT book , (codes 15830 – 15839) some  payers have "tagged" these codes as being not medically necessary and or cosmetic based procedures.  However, the CPT definition states nothing in relation to that assumption of that in the coding guidelines.  The codes of 15830 – 15839 the base code of 15830 states "excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilcal panniculectomy .

If you compare and contrast the CPT procedure codes of 15839 and 56620, it is clear how difficult coding choices are, if the documentation is not clear, or the physician has not included or “tied together” a straightforward diagnosis and medical necessity for the surgical procedure. 

15839 56620

excision excessive skin&subq tissue other area simple vulvectomy (Note Work RVU only)

RVU = 10.50 RVU = 08.44

The lay descriptions for codes 15830-15839 is

“The physician removes excessive skin and subcutaneous tissue (including lipectomy).  In 15830, the physician makes an incision traversing the abdomen below the belly button in a horizontal fashion. Excessive skin and subcutaneous tissue are elevated off the abdominal wall and excess tissue and fat are excised. The flaps are brought together and sutured in at least three layers. The physician may also suture the rectus abdominis muscles together in the midline to reinforce the area. Report 15832 for removal of excess skin and subcutaneous tissue on the thigh; 15833 for the leg; 15834 for the hip; 15835 for the buttock; 15836 for the arm; 15837 for the forearm or hand; 15838 for the submental fat pad (inferior to the chin); and 15839 for any other area.”

The Lay description for code 56620 is

“The physician removes part or all of the vulva to treat premalignant or malignant lesions. A simple complete vulvectomy includes removal of all of the labia majora, labia minora, and clitoris, while a simple, partial vulvectomy may include removal of part or all of the labia majora and labia minora on one side and the clitoris. The physician examines the lower genital tract and the perianal skin through a colposcope. In 56620, a wide semi-elliptical incision that contains the diseased area is made. ….”

Now to compare and contrast what happens in the real world of coding, take a look at a case study of the CPT code 15839 and CPT code 56620 vulvectomy simple;partial.   As you can see the work RVU for the code 15839 is more than the code for the 56620.

Case study comparison:

History: Patient presents with labial hypertrophy (congenital) and wishes to have a labiaplasty to even up both sides of the labia.  Patient reports tearing due to excessive length on the left side, excessive skin gets caught in clothing, and is uncomfortable when sitting for long periods of time, or becomes irritated due to her clothing.  Upon examination patient has a class 3 hypertrophy, involving the clitoral hood.   ICD-10cm diagnosis = N90.6 Hypertrophy of vulva; Hypertrophy of labia.  The physician and patient formally decide to do a labiaplasty as an outpatient procedure . The physician schedules the surgery and performs a labiaplasty.

Procedure: The risks, benefits, indications and alternatives of the procedure were discussed with the patient and informed consent was signed. The patient was then taken to the procedure room and prepped and draped in the usual sterile fashion. The labia and clitoris were then marked using the marking pen to the patient's specifications.   The perineal area was infiltrated first with the creation of a small bleb followed by infiltration of the labia majora up to the clitoris on the left side. The labia minora was then infiltrated along the lines of demarcation.  It was then clamped using Heaney clamps and the tissue excised. The clamped tissue was then cauterized using a single tip Bovie.  Excellent hemostasis was confirmed. The clitoral hood was then trimmed using scissors. The exposed tissue of clitoral hood and labia were re-approximated using 3-0 Monoderm.  Excellent hemostasis was noted. This completed the procedure. The patient tolerated the procedure and was discharged home in stable condition.  Tissue sent to Pathology – no neoplasm noted, no abnormalities noted.

In the above scenario, the coder is confused regarding which code to use, and queries to provider.   The physician responds to the query and states CPT code 15839 with dx code N90.6 is the procedure and DX that should be billed.  The physician also responded back to the coder, that he did not feel that he performed a “simple vulvectomy” because only a minimal portion of the labia was involved, as the tissue that was removed was not diseased or compromised by lesions, or other symtoms, as borne out by the pathology report.   He stated this was simply a congenital abnormality of one side was “longer” than the other. 

A few weeks later, the coder then has another labiaplasty operative report, from the same physician,  however this one is for a patient who has an ongoing issue with syringoma of the vulva (as borne out by pathology biopsy)  In this operative scenario, the coder chose to code the 56620, as this was clearly a disease process. 

Operative Report:   Patient had previous biopsy for syringoma(confirmed) D28.0 Benign neoplasm of vulva.  The labia has become enlarged and patient opted for removal as it was becoming bothersome and growing at a rapid rate. 

Findings:  three 5 mm intradermal lesions on the patients left labia and two 3mm intradermal lesions on the patients’ right laboria majora approximately 2 cm posterior to the clitoris. 

Procedure:  The patient was taken to the operating room with an IV in place.  MAC anesthesia was begun.  Pt placed in lithotomy position, prepped and draped.  Area was previously identified and marked with marking pen.  Two small elliptical incisions approximately 3cm were made on either side of the lesions.  A 15 blade was used to make an incision.  The lesions were excised from the underlying tissue .  Incisions were sewn back totether with running subcuticular stiched with 3-0 vicryl.  The patient tolerated the procedure and was discharged home in stable condition.  Tissue sent to Pathology – confirmed all lesions were denoted as syringoma. 

If the coder were coding for this procedure in ICD-10 pcs it is much more straightforward, as the code would be OUBMXZZ, where as with CPT, it is subjective between diseased tissues and normal tissues.

Another coding and billing issue that these two codes (15839 and 56620) can present, is code 15839 has a larger RVU, and could be billed as a bilateral procedure, which would have a higher financial reimbursement, than the 56620 code, which cannot be billed as a bilateral procedure and has a lower RVU value attached.  Therefore, the coder must make sure that the code choice for billing is based purely upon documentation and physician notation reflected in the operative reports, and not based upon obtaining a higher reimbursement strictly for financial purposes. 

OB/GYN is not the only specialty where this type of issue is found.  Coding for the excision of soft tissue tumors are found in the musculoskeletal section of CPT.  A soft tissue tumor,  such as a lipoma  that is in the subfascial, or subcutaneous area should be coded to the musculoskeletal section with the code range of 22900 – 22905.  Whereas,  if the lesion is a sebaceous cyst, the code choice should be from the 11400-11406 integumentary codes.  If the diagnosis is a melanoma of the skin, it might be more appropriate to use 11600-11606 for a radical resection.   If the tumors are intra-abdominal (not cutaneous or musculoskeletal) then the codes 49203 – 49205 would be more appropriate. 

Again, this is where the coder needs to truly understand the anatomy of “what” was excised, “where” it was excised, and the pathology of the tissue or masses/lesions that were excised.  The physician is responsible for documenting clearly the diagnosis, the procedure and medical necessity.  This also includes “connecting” the pathological findings back to the operative notes.  Good clinical and operative documentation is imperative for the coder/biller, the medical record documentation, the payer/insurance carrier and the patient.  The coder has the ethical and moral obligation to code what is documented without regard to financial gain.  With this in mind, the coder also needs to be aware that CPT has many surgical codes that “overlap” or are very similar.   As a coding practice standard, all coding possibilities should be reviewed carefully, then code based upon the clinical documentation.

If you are in doubt, query the provider!  Many coders rely on the old adage of “if it wasn’t documented, it wasn’t done”.   This type of coding should no longer be the rule of thumb or status quo.  If the clinical documentation denotes a service/ procedure was performed,(but poorly documented) it is well worth the time to investigate, confirm, and/or have the operative record amended by the provider, then coded and billed with accuracy.   If the insurance carriers deny your coding/billing as a “cosmetic” procedure, and the clinical documentation supports true medical necessity (not just convenience for the patient) be sure to appeal and provide the substantiating medical records to support your coding.

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/.  

Computer Assisted Coding – Where are we today?

Some good Information for us that actually work with computer assisted coding.  

*********************************************************************************Originally posted from Justcoing.com August 19, 2016 (as written by me!) 

In our computer-saavy tech world, the medical field has been notoriously slow to respond to newer technologies and applications of computer assisted enhancements.   However, in the HIM market, computer-assisted coding , (aka CAC)  has been touted to boost coding accuracy and productivity, in addition to being a terrific tool for the “remote” or “at home” HIM/inpatient coder. 

Background

“The term computer-assisted coding is currently used to denote technology that automatically assigns codes from clinical documentation for a human…to review, analyze, and use.”   Currently,  there are a variety of methodologies software, and integration interface applications that enable a CAC  application to  “read” text and assign codes.  This type of software “reads” the information in a similar way to how a “spell-check” application works on a traditional computer.    According to some users, the data driven documentation (eg.  dictated/typed etc.) is more accurate from the CAC than documents that are scanned into the matrix for the CAC to utilize.   

CAC software works on a recognition premise, and “learns” words and phrases, as well as “learning” the areas within a  specific document as to where standardized words and phrases appear, (eg similar to a macro).  CAC software also has the ability to discern the context and or “meaning” of specific words and phrases.   The CAC then analyzes and predicts what the appropriate codes (ICD-10cm and pcs) should be for the documented procedures and diagnoses it finds within the specified documents.  

Computer-assisted coding (CAC) software has been available for over 10 years, but has really come to the forefront of inpatient coding with the implementation of ICD-10cm and ICD-10pcs and a way for hospitals to reduce charge lag-times and enhance DRG’s and find those “missed” MCC/CC diagnoses.  The usage and integration of an electronic health record (EHR) into a CAC has also been a factor for better code assignment and usage by the CAC for data analysis and outcomes.  However, it is yet to be shown that a CAC actually “enhances” a coders’ productivity rate.  On the up-side a CAC does give the coder a great place to “start” when working on a large difficult inpatient record.   A CAC is now where we were 20+ years ago when “encoders” were first introduced into the inpatient hospital marketplace for coding, abstracting and data analysis.

Pros and Cons of CAC 

Due to the complexity of inpatient care records, clinical documentation and the complexity of medical terms and abbreviations used, many hospitals don't have,  or only use the CAC with “real coder”  intervention.  However, the latest CAC software technology employs a type of natural language and syntax processing to compare, contrast and extract specific medical terms from the electronic data or typed text.   The CAC stand-alone technology does exist, however in studies by AHIMA, the “combination” of a CAC with a coder/auditor has been proven to be as good or better than a “coder” alone,  or a “CAC” alone. 

Yet, the biggest Pro/Cons of a CAC is getting the buy-in of the hospital coding and HIM staff.  As the medical field is ever-changing; the HIM, coding and clinical staff must all be a part of the changes and be on-board to this new technology enhancement to their job.  In the past, there has been some uncertainty and fear related to job-elimination of coders in regard to a CAC implementation at the facility.  However, a good CAC  in conjunction with  HIM management utilization of both, allows coders to apply their critical thinking and analytical coding knowledge skills to create a well coded documentation of the patients’ care.  This in turn,  relates to better DRG and reimbursement for the facility. 

The HIM and coding staff responsibility and role in the fiscal revenue stream will change.  With this change comes the acceptance that it takes both a “human” and a “computer” to successfully transform a CAC product into good financial outcomes and even better coding documentation.  

Coders are quick to agree that the final code selection for inpatient records should be based upon their knowledge of coding guidelines, clinical concepts, and compliance regulations.  When working in tandem on a CAC, the coder has the ability to override and agree/disagree with the codes that the CAC determines.

    

Coders have the education to understand why a diagnosis or procedure is, or is not coded, and with that by using the CAC, they can help the CAC “learn” to distinguish the importance of specific documentation and it’s relation to ICD-10 cm/pcs codes. 

Many CAC vendors will try and “sell” their product based upon this listing of “Pros”…

·         Increased medical coder productivity

·         Return on investment that quickly pays for CAC system

·         Faster medical billing

·         More revenue from more detailed bills

·         Greater medical coder satisfaction

·         Better  medical coding accuracy

·         Identification of clinical documentation gaps

·          

It has been highly touted that CAC’s in optimize coder productivity.  However, in reality, productivity will probably stay the same, as the coder will still have to “audit” the information to determine if, in fact, the CAC code is correct.   In regard to the other “pros” on the vendor list, coder satisfaction should not be overlooked. 

According to AHIMA’s pilot testing of CAC’s , they weighed in on some of the potential issues with a CAC use only.  However, these potential areas of concern can be addressed quickly if the coder uses the CAC to audit the case prior to any claims sent to insurance carriers.   AHIMA noted that within “specific” areas of the pilot CAC testing in ICD-10, the coders did not accept 75% of the diagnosis codes presented, and did not accept 90% of the procedure codes presented within the ICD-10cm and ICD-pcs codesets.   However, the information that the CAC presented, did give the coders a good “starting” reference to drill down to a more comprehensive code for both diagnosis and procedures. 

Coders and CDI personnel will still need to be the ones charged with

·         Ensuring clinical documentation is complete and query when appropriate. 

·         Ensuring complete coding (eg for 4^th and 5^th digits/specificity)

·         Ensuring correct sequencing of diagnosis and procedures

·         Reviewing of correct MCC/CC’s  and DRG assignments with case complexity and severity

CAC, Clinical Documentation, EHR, and Providers’

Integration of clinical documentation by provider and physicians has always been a challenge combined with the  and the implementation of ICD-10 in 2015  has been a huge impetus for CAC utilization for hospital and facility based organizations.  Unfortunately, physicians still don’t provide thorough documentation and rely on CDI and coding staff to guide them.  There has always been a HUGE disconnect in the language spoken by “providers” and the language spoken by “coders”.  Physicians document in their comfort zone, and fall back on those terms such as “pneumonia”.  Whereas a coder, they are looking for much more specificity.  The integration of an EHR based program for the physician/providers to use and a CAC providers a good “team relationship” for both parties. 

Many CAC programs extend out and integrate well with hospital based CDI programs and EHR’s.  These combination computer interfaces allow more “real time” processing of “possible” code selection prior to the final code selection being audited and reviewed by the coder.  When the CAC identifies these “possibilities” the opportunity exists to identify and improve the DRG’s with MCC/CC’s , and address more quickly areas for query, and missed procedures or diagnoses. 

Case Study to make It work:

The scenario below (provided from  Smith, Gail I.; Bronnert, June. "Transitioning to CAC: The Skills and Tools Required to Work with Computer-assisted Coding" Journal of AHIMA 81, no.7 (July 2010): 60-61.)

ICD-10-CM CAC Example

In the example below, the CAC software assigned the code T15.91A based on documentation in the emergency department record that states the patient had a "foreign body in the right eye." The coder is presented with the decision to accept the code or reject it based on further analysis.

Emergency Department Record

A patient is brought to the emergency department due to a foreign body in the right eye. He was working with metal, and a piece flew in his eye. He reports slight irritation to the right eye but no blurred vision.

A slit lamp shows a foreign body approximately 2–3 o'clock on the edge of the cornea. The foreign body appears to be metallic. The iris is intact.

Procedure: Two drops of Alcaine were used in the right eye. Foreign body is removed from the right eye.

CAC: Computer-Generated Codes: T15.91xA, Foreign body, external eye, right.

Final Coding Decision: T15.01xA. Foreign body of cornea,

Review of the documentation in the record by the coder and then the information from the CAC,  revealed that the foreign body was located on the edge of the cornea, which changes the fourth character in ICD-10-CM from 9 to 1. The coding professional replaces the T15.91xA code with T15.01A, Foreign body in cornea, right eye.

Wrapping it all up

The above scenario is a very simplistic case study, but an important one, as it shows and validates the importance of the coder as the “knowledge” behind the “technology”.   Coders and HIM professionals need to make a commitment to embracing change which includes “new” technologies and integration of learning processes and opportunities.  A hospital’s success depends on the “knowledge” worker as part of the ongoing and ultimate team member for successful outcomes for both patients and hospital fiscal solvency. 

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/.   

“Fixing” past issues to embrace the “Future” -- ICD-10cm: In our sights…

.. Originally published by JustCoding.com as written by me...  

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“Fixing” past issues to embrace the “Future” --  ICD-10cm: In our sights…

Lori-Lynne Webb

August 1, 2015

As coder and billers we are a pretty flexible group.  Overall we are excited to get started and forge ahead with ICD-10.  However, before we can fully embrace this future of great documentation, with new and different coding strategies, we must “Tidy up”  after ourselves, and not leave our “coding house” a mess before ICD-10 arrives.  

Too often we get busy, lazy, complacent, or just don’t realize what is still left out there to do before we begin anew with ICD-10cm.  All of us have our “bad habits” and science has proven it takes at least 4-6 weeks to change a bad habit.  We will begin a quick run-down on some “quick fixes” to jump start your “clean up” before ICD-10 arrives.   These areas of improvement are not in any specific type of “order”, just good places to begin.

Update Encounter/Superbill forms:

When was the last time you took a good, hard look at your encounter/superbill forms?  If they haven’t been updated lately, you may be leaving $’s on the table.  Most importantly, if you’re not getting a good diagnosis code to go with the office visit or procedure that has been performed, no only are you potentially missing revenue, but the patient care is affected when the diagnosis is not clearly specified.  

ICD-10cm and the large volume of specificity this code set brings for diagnosis coding will make it a lot more difficult to easily have diagnosis codes included on paper encounter forms.  If this is the case, you may want to consider dropping the diagnosis “check boxes” from encounter forms and ask the provider to give you a “handwritten” specific diagnosis, that can be corroborated with review of the actual documentation.  These handwritten diagnoses will need to include laterality and specificity. 

The coder then is able to take these handwritten diagnoses and do what a coder does BEST -  Code the claim based upon the documentation provided.    If the physician is the one to actually “choose” the code or “enter” a diagnosis code  into the EMR/EHR, you may need to provide a good cross/reference tool for the provider to refer to that is NOT a part of the encounter/superbill form.    By “cleaning up” this process you can potentially see for the practice:  a) more accurate diagnosis documentation b) more accurate claim submitted c) less claim rejections, d) revenue stream flows more smoothly with less “outstanding” claims.

What is in your top 25?

If you don’t know what your top 25 diagnoses are, you should make this a priority to find out.  Most practices submit many of the same diagnosis day in and day out.   Take the time to find out those diagnosis codes and create a good, cross reference tool to be used that gives the provider the “old” ICD-9 code and the potential “new”  ICD10cm codes.  In some cases, you may be able to give the provider a direct 1-1 match, in other cases it may be far more.  Once you know your top 25,  then dig into the documentation of those case files to see if the diagnosis documented in the old files really stand up to what will be needed in ICD-10.  If not, this is the prime time to get that “fix” put in place.  Communicate with your providers to create good macro’s, templates, and verbiage to help them with documenting clearly and concisely to jointly create good patient care outcomes, in addition to good claims and reimbursement outcomes.

GIGO?  Garbage In, Garbage Out

If you’ve not heard this term before, it is something to think about.   GIGO is an acronym that stands for "Garbage In, Garbage Out." GIGO is a computer science acronym that implies bad input will result in bad output.  In regard to coding and billing, If you put “garbage in the revenue stream, you are going to get garbage back out”.   As coders, we want to be putting in the best information possible to have the best outcome on our revenue and claims payments.  In July 2015, CMS came forth and stated that when ICD-10cm is implemented they will not deny claims if the billed code is in the “family” of codes.  This can be confusing for coders who rely on specificity and want to have the best code chosen for what is documented.  CMS did clarify what is meant by “family of codes”  in a Q&A release updated on July 31, 2015.  (https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf) 

“CMS has defined the “Family of codes” to be codes within the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition.” 

 Even though CMS has stated they will not “deny” the claim if your diagnosis is within the family, however, the best option is to code to what is documented.  The G.I.G.O. theory goes hand in hand with the adage “if it wasn’t documented, it wasn’t done”.  As a coder, perform your due diligence and be sure that you are currently coding to the best of your ability and coding to the best specificity NOW, and don’t wait till implementation date to make this change. 

If you are putting good information in, you will have cleaner claims coming out, and less “fixes” and “appeals” to be done on the backside.  Anytime you have to re-code and re-submit a claim it not only costs you time, but costs your practice money as well. 

What is happening on your “front end”?

In regard to the GIGO theory, be sure to check what is happening on the “front end”.  If patients are not being registered into the demographic/patient management system correctly, this can be another “glitch”.  Eliminating and avoiding demographic claim denials is essential to a good coding and billing  team practice.  Demographic errors can hold up revenue, and saddle your coding/billing staff with unnecessary work to clean them up and rebill those claims.   

This is now the perfect time to work with the front end/front office staff to spruce up and smooth out any demographic hold-ups in the registration and check in processes prior to the ICD-10 go live.  Work with your front office colleagues to get good documentation reported and documented in the patient medical and billing record.  Always ask (each visit) for the patient’s most current address, phone, e-mail, work, insurance, payment plans, or other pertinent information to help create a good medical information record/documentation file. 

Many patients have changing insurance carriers and coverage with the implementation of Obama-care.  If the front office staff can't gather current pertinent information before the appointment, have them ask for it as soon as the patient arrives.  If you need a referral or pre-authorization before the patient is seen, obtain it as soon as possible, in addition to collecting co-pays, verifying deductible status,  verifying eligibility and benefits.  And, don’t forget the importance of the ABN/waiver form if a service is not covered.  Patients need to be informed and understand their financial responsibility to the clinic if a service is not covered.  

Last but not Least….

Coders have an extremely important role in the medical office, and with the upcoming ICD-10 roll out, this last list of tasks may seem obvious, but the importance cannot be discounted to having a successful transition to ICD-10

1.     Focus on “Quality” not “Quantity” or other measures of coder productivity. The quality of coded data is more critical considering the amount of new codes in ICD-10 and specificity. 

2.     Try to eliminate as many of the daily distractions and disruptions in the workplace as possible. (eg avoid GIGO to ensure clean claims the first time through)

3.     Communicate, Query and Educate all members of your office team.  Be exceptionally diligent, yet helpful,  with the providers when you find conflicting and incomplete diagnosis documentation in the patient record.  We are all in the learning curve, in trying to master coding with the new ICD-10 codeset.
 

4.     Fix it first – Submit it second.  If you find an error, fix it when you find it.  If you wait, it may get lost in the shuffle, then create more work, later. ( eg wrong patient address, wrong insurance, etcc)

5.     Take time to educate and review the official ICD-9cm AND ICD-10cm coding guidelines for both outpatient and inpatient diagnosis billing.  If you review both sets, you will be able to clearly understand the similarities and differences that can be critical to your claim and diagnosing success.

6.     Perform full-spectrum chart audits in your practice to help resolve and create good coding and billing success. A good plan includes pre-claim, and post claim audit.  Closely look at the medical necessity and linking of diagnosis to documentation.  Follow up your audits to see if they were submitted correctly, adjudicated correctly and paid correctly.   

7.     Provide “coding tools” in an electronic format.  Have the ICD-10 codeset available to providers and staff  in a PDF form on their computer desktop, have a handy top 25 cross-coder available for them. Share helpful hints with everyone.  A good “team” approach to collaboration and communication enhances the potential for better office flow and successful patient experiences and care.

8.     CELEBRATE YOUR SUCCESSES!!!   Celebrations don’t have to be “expensive”  but a quick “good job”, “Thank you for your help”, “Great Idea - let’s try it”, or even a simple “high-five”  go a long way when entrenched in the stresses of change. 

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/.  

Coding and Billing for Infertility services and procedures

Coding and Billing for Infertility services and procedures

Originally Published: July 16, 2016

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC

Infertility is one of those topics that not many men or women openly discuss.  In the medical community, we look at this as a diagnosis that needs evaluation and treatment, if there are viable options available for you.  

According to the AIUM (American Institute of Ultrasound in Medicine©) they define female infertility as:

"Female infertility shall mean the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35. For purposes of meeting the criteria for infertility in this section, if a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1 year or 6 month period, as applicable."

According to the Mayo Clinic (© 1998-2016 Mayo Foundation for Medical Education and Research) Male infertility is defined as:

“A male's inability to cause pregnancy in a fertile female in light of unprotected sexual intercourse for a year or longer.”   

Treatment Options

There are many varied treatments for fertility issues.  However, the root cause of the infertility will drive what options are utilized.  In women, infertility may be caused by ovary dysfunction, blocked or damaged fallopian tubes, uterine disease processes such as fibroid tumors or endometriosis, cervix  stenosis, endocrine hormone dysfunction and in some cases, stress and/or medication side effects.  It has been noted in some studies that up to 15% of infertility cases, the actual cause may remain unexplained. In men, infertility may be caused by obstruction of the testes, epididymis, vas deferens, ejaculatory duct, distal seminal ducts, varicocele, hypogonadism, cryptorchidism, reproductive gland infections, ejaculatory disorders, or hormonal deficiencies with testosterone or endocrine malfunction.  

Female infertility can be treated in several ways, including:

• Laparoscopy: This is usage of a surgical technique using a laparoscope to remove any scar tissue, endometriosis, ovarian cysts or open/re-open blocked fallopian tubes.

• Hysteroscopy: Is usage of a hysteroscope, placed into the uterus which can be used to remove polyps, fibroid tumors, endometriosis, scar tissue, open/re-open blocked fallopian tubes.

• Medical therapy: (Drug therapy for ovulation problems) Medications prescribed such as clompiphene citrate (Clomid, Serophene), letrozole, or gonadotropins can help induce ovulation,  Other drugs such as Metformin (glucophage) may be prescribed for women who have insulin resistance, or PCOS (Polycystic Ovarian Syndrom)

• Intrauterine sperm insemination: ISI refers to an office based  procedure where semen is collected, rinsed with a special solution, and then placed into the uterus at the time of ovulation.  

• In vitro fertilization:  IVF refers to a procedure in which eggs are fertilized in a culture dish and placed into the uterus.)

•Intracytoplasmic Sperm Introduction: ICSI is a procedure where sperm is injected directly into the egg in a culture dish and then placed into the woman’s uterus

• GIFT (Gamete intrafallopian tube transfer)/ ZIFT (zygote intrafallopian transfer): These procedures are similar to IVF.  Both procedures involve retrieving an egg combining with sperm then transplanting back into the uterus. (In ZIFT, the fertilized eggs -- at this stage called zygotes -- are placed in the fallopian tubes within 24 hours. In GIFT, the sperm and eggs are mixed together before being inserted.)

• Egg donation: The egg donation procedure involves the removal of eggs from the ovary of a donor, then placed mixed with the sperm from the recipient's partner and transplanted into the uterus via the IVF procedure.

In men there are fewer procedural options for infertility

• Microsurgical Epididymal Sperm Aspiration (MESA) or Testicular Sperm Extraction (TESE): In men, if the semen sample(s) contain no spermatozoa due to a congenital obstruction of the sperm ducts, vasectomy, failed vasectomy reversal or primary testicular failure. A patient can have the physician retrieve sperm surgically from the epididymis (MESA) or from the testis (TESE). Once the retrieval is performed, the sperm can then be frozen and/or used for fertilization by the ICSI method.
• Varicocelectomy:  This is procedure in which a cluster of varicose veins around the vas are removed or tied off. Urologists have stated that there is a possibility that due to increased blood circulation around these veins, it is thought to increase testicular temperature and reduce sperm production.
• Testicular biopsy: This is a procedure in which small portion of tissue is removed from both testicles and sent for histological laboratory examination.  If there is a zero sperm count and the testicles are of normal size, the cause may be an obstruction to sperm outflow or a failure of the testicles to produce sperm.  If the biopsy will determine if there are sperm in normal numbers, or show a zero sperm count, in which it is more likely due to an obstruction.

ICD-10cm code set guidelines

In ICD-10cm the N97 codes represent the diagnosis of female infertility, and it “excludes” those codes associate with hypopituitarism (E23.0) and Stein-Leventhal Syndrome (E28.0) both of which are found in chapter 4 which contains the codes for endocrine, nutritional and metabolic diseases, rather than those in chapter 14 which are diseases of the genitourinary system.  When assigning an infertility code as a patients’ diagnosis, make sure that the physician has clearly denoted that the patient truly is “infertile” and documented this diagnosis as such.  If however, the physician has documented that a patient has other symptoms that could be construed as “infertility”  it is important that you, as the coder, do not make the inference that the patient is diagnosed with infertility.  

There are many diagnoses that may mimic infertility, or contribute to an infertile state, such as salpingitis, oophoritis, metritis, myometritis, pyometra, uterine abscess, pelvic peritonitis, pelvic abscess, endometriosis, and a host of many other diagnoses that may play a part in a patients ultimate diagnosis of infertility.  However, if the physician only mentions that the patient may be infertile due to one of the above, then ask your provider to denote if the patient has primary infertility due to a specific disease process, or if the patient has a secondary infertility due to a specific disease process.  Clarity and transparency of the diagnosis is critical for coding accuracy.  The same theory holds true for men.  It is imperative for the provider to be very specific when coding an infertility diagnosis, or coding a “symptom” or other “disease process” as the primary diagnosis.  If this is the case, then the infertility code would be a secondary code on your claim.

ICD-10cm code set for female infertility:

N97 Female infertility

Includes: inability to achieve a pregnancy, sterility, female NOS

Excludes1:  female infertility associated with: hypopituitarism (E23.0) Stein-Leventhal syndrome (E28.2)

Excludes2:  incompetence of cervix uteri (N88.3)

• N97.0
• Female infertility associated with anovulation
• N97.1
• Female infertility of tubal origin
• Female infertility associated with congenital anomaly of tube
• Female infertility due to tubal block
• Female infertility due to tubal occlusion
• Female infertility due to tubal stenosis
• N97.2
• Female infertility of uterine origin
• Female infertility associated with congenital anomaly of uterus
• Female infertility due to non-implantation of ovum
• N97.8
• Female infertility of other origin
• N97.9
• Female infertility, unspecified

ICD-10cm code set for male infertility is found within the chapter 14 “N” codes too.  Male infertility is represented with the codes of N46 and excludes the code Z98.52 which represents a vasectomy status.

• N46 Male Infertility
• N46.0: Azoospermia
• N46.01: Organic azoospermia
• N46.02: Azoospermia due to extratesticular causes
• N46.021: Azoospermia due to drug therapy
• N46.022: Azoospermia due to infection
• N46.023: Azoospermia due to obstruction of efferent ducts
• N46.024: Azoospermia due to radiation
• N46.025: Azoospermia due to systemic disease
• N46.029: Azoospermia due to other extratesticular causes
• N46.1: Oligospermia
• N46.11:  Organic oligospermia
• N46.12:  Oligospermia due to extratesticular causes
• N46.121: Oligospermia due to drug therapy
• N46.122: Oligospermia due to infection
• N46.123: Oligospermia due to obstruction of efferent ducts
• N46.124: Oligospermia due to radiation
• N46.125: Oligospermia due to systemic disease
• N46.129: Oligospermia due to other extratesticular causes
• N46.8: Other male infertility
• N46.9: Male infertility, unspecified

CPT procedures associate with infertility

Below is a table with the most common CPT procedures that are used for treatment of infertility.  This includes procedures for both men and women.  I have also included a table that shows many of the lab procedures that can be performed for infertility.  If you code and submit claims with HCPCS there is also a table for the HCPCS codes.

CPT Coding:

10021	Fine needle aspiration; without imaging guidance
10022	Fine needle aspiration; with imaging guidance
54500	Biopsy of the testis, needle
54800	Biopsy of epididymis, needle
55200	55200 Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure)
55400	Vasovasostomy, vas vasorrhaphy
55870	Electroejaculation (may be used in patients who are unable to produce a normal ejaculate due to spinal cord or other nervous system disorder i.e., diabetic neuropathy)
58321	Artificial insemination; cervical
58322	Artificial insemination; intra-uterine
58323	Sperm washing for artificial insemination
58345	Transcervical introduction of fallopian tube catheter for diagnosis AND/OR re-establishing patency (any method), with or without hysterosalpingographpy
58350	Chromotubation of oviduct, including materials
58750	Tubotubal anastomosis (Sterilization reversal)
58752	Tubouterine implantation  (Sterilization/tubal blockage tx)
58760 58672	Fimbrioplasty (reconstructive to restore patency of occluded fimbriae) Laparoscopic Fimbrioplasty
58770 58673	Salpingostomy (microsurgery to restore tubal patency) Laparoscopic Salpingostomy
58970	Follicle puncture for oocyte retrieval, any method
58974	Embryo transfer, intrauterine
58976	Gamete, zygote or embryo intrafallopian transfer, any method

CPT Lab/Pathology tests commonly performed for infertility

89250	Culture of oocyte(s)/embryo(s), less than 4 days
89251	Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos (investigational)
89253	Assisted embryo hatching, micro techniques (any method)
89254	Oocyte identification from follicular fluid
89255	Preparation of embryo for transfer (any method)
89257	Sperm identification from aspirate (other than seminal fluid)
89258	Cryopreservation; embryo(s).
89259	Cryopreservation; sperm.
89260	Sperm isolation; simple prep (e. g., sperm wash and swim-up) for insemination or diagnosis with semen analysis
89261	Sperm isolation; complex prep (e. g., Percoll gradient, albumin gradient) for insemination or diagnosis with semen analysis.
89264	Sperm identification from testis tissue, fresh or cryopreserved
89268	Insemination of oocytes
89272	Extended culture oocyte(s)/embryo(s), 4 – 7 days
89280	Assisted oocyte fertilization, micro technique; less than or equal to 10 oocytes
89281	Assisted oocyte fertilization, micro technique; greater than 10 oocytes
89290	Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos
89291	Biopsy, oocyte polar body or embryo blastomere, micro technique (for pre-implantation genetic diagnosis); greater than 5 embryos (non-covered)
89300	Semen analysis; presence AND/OR motility of sperm including Huhner test (post coital)
89310	Semen analysis; motility and count (not including Huhner test)
89320	Semen analysis; volume, count, motility, and differential
89321	Semen analysis; sperm presence and motility of sperm, if performed
89322	Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger)
89325	Sperm antibodies
89329	Sperm evaluation; hamster penetration test
89330	Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test
89331	Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)
89335	Cryopreservation, reproductive tissue, testicular
89337	Cryopreservation, mature oocyte(s) (investigational)
89342	Storage, (per year); embryo(s)
89343	Storage, (per year); sperm/semen
89344	Storage, (per year); reproductive tissue, testicular/ovarian (investigational)
89346	Storage, (per year); oocyte (investigational)
89352	Thawing of cryopreserved; embryo(s)
89353	Thawing of cryopreserved; sperm/semen, each aliquot
89354	Thawing of cryopreserved; reproductive tissue, testicular/ovarian (investigational)

HCPCS Coding:

S3655	Antisperm antibodies test (immunobead)
S4011	In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development
S4013	Complete cycle, gamete intrafallopian transfer (GIFT), case rate
S4014	Complete cycle, zygote intrafallopian transfer (ZIFT), case rate
S4015	Complete in vitro fertilization cycle, NOS case rate
S4016	Frozen in vitro fertilization cycle, case rate
S4017	Incomplete cycle, treatment canceled prior to stimulation, case rate
S4018	Frozen embryo transfer procedure canceled before transfer, case rate
S4020	In vitro fertilization procedure cancelled before aspiration, case rate
S4021	In vitro fertilization procedure cancelled after aspiration, case rate
S4022	Assisted oocyte fertilization, case rate
S4023	Donor Egg cycle, incomplete, case rate
S4025	Donor services for in vitro fertilization (sperm or embryo), case rate
S4026	Procurement of donor sperm from sperm bank
S4027	Storage of previously frozen embryos
S4028	Microsurgical epididymal sperm aspiration (MESA)
S4030	Sperm procurement and cryopreservation services; initial visit
S4031	Sperm procurement and cryopreservation services; subsequent visit
S4035	Stimulated intrauterine insemination (IUI), case rate
S4037	Cryopreserved embryo transfer, case rate
S4040	Monitoring and storage of cryopreserved embryos, per 30 days
S4042	Management of ovulation induction (interpretation of diagnostic tests and studies, non-face-to-face medical management of the patient), per cycle

Coding, Billing, Medical Necessity and Insurance Plan Coverage

Correct coding is important to you, and your physicians. The ICD-10cm diagnosis and the CPT procedures need to be linked appropriately, and clearly show the “reasons” or “medical necessity” of the testing or procedures being performed. The most common denial from insurance carriers is “procedure is deemed not medically necessary”.  

Coding for infertility can and is complicated, and errors are not uncommon.  Coders need to clearly understand the most common codes utilized in infertility procedures and diagnosis.  Best practices contact the patient and obtain prior authorization and check insurance benefits before scheduling and/or performing any major infertility procedures.  

Pre-authorization and medical review have become necessary components for payment by 3rd party payers such as insurance companies.  These carriers carefully review the patients’ policy, and will advise of any conditions or policy criteria that specifically addresses infertility treatments.  It has become commonplace language in most insurance policies, that all medical treatment be “medically necessary” not just treatment for infertility.  Unfortunately, some insurance carriers provide minimal or even no payment for infertility testing or procedures.  When pre-authorizing for infertility testing, or infertility procedures be sure to carefully review and discuss the patients’ policy with the patient, and then have the appropriate ABN signed, and/or financial commitment for payment if the insurance company does deny, or if the patient does not have any 3rd party coverage at all.

If the patient does have coverage, and the claim is denied, always appeal the claim with a copy of the patients’ policy and the expectation of what the carrier should pay toward the claim. The denial code CO50, is commonly seen on infertility claim denials, and is defined as: “non-covered services because this is not deemed a ‘medical necessity’ by the payer.”  If your claim is received with this CO50 claim denial, your office will need to provide the carrier additional information to support medical necessity, which is documented in the physician/provider chart notes.  In addition to sending the medical documentation, you may also want to include an additional letter or appeal from the provider stating why the physician feels the procedure is medically necessary.  Another area of concern, when the claim has not been reimbursed, is there may be a notation on the denial from the carrier stating the patient is not responsible for the charges.

Another denial code commonly seen with infertility claims is denial code CO96; Non-covered charge(s), or denial code CO48; This (these) procedure(s) is (are) not covered by your policy.  

If the insurance carrier adjudicates the claim with a CO96, or CO48 adjudication codes, it will also notate in the remark codes if the patient is responsible for the charges.  However, If you are billing a Medicare claim, it is advisable to obtain an ABN (Advance Beneficiary Notice) signed by the patient.  If the patient has a private insurance carrier, have a similar document signed and on file by the patient.  

Some carriers, in addition to Medicare and Medicaid, allow for usage of the modifier “GA” on the claim. The GA modifier indicates that the expected denial is for a service that is considered to be not reasonable and/or medically necessary, nor is it expected to be paid for by Medicare and/or Medicaid Services (or the private carrier).  If the claim is billed to a Medicare/Medicaid carrier and the GA modifier is used, the remittance advice will notate that the patient is responsible for the charges incurred.

Operative Records/Clinical Documentation

Included below is an operative report for your review, the CPT codes are those which are actually documented within the report, however, you will note that there is a modifier 59 appended to the chromotubation code.  When these codes were run through the CCI bundling edits, the 58350 was considered “bundled” with the other three codes, however, CCI states that a modifier 59 is permitted if appropriate.   In this operative report, the chromotubation is performed to assess where the blockage is within the fallopian tube.

OPERATIVE REPORT #1

PREOPERATIVE DIAGNOSES: Chronic pelvic pain , endometriosis, infertility .

OPERATION PERFORMED: Operative laparoscopy, lysis of adhesions, right fimbrioplasty, tubal insufflation.

ANESTHESIA: General.

OPERATIVE INDICATIONS AND FINDINGS: 26yo G1P1 with a long history of pelvic pain and known endometriosis with a documented 24 months of infertility.  She underwent an operative laparoscopy a little more than 6 months ago with findings of massive pelvic endometriomas, and endometriosis of the uterus.  Multiple fulgurations were performed and cystectomies.

At time of this surgery, the pelvis is dramatically better, but there is obvious evidence immediately of active endometriosis.  The bladder flap was peppered with active endometrial implants.  There were implants along both lateral pelvic sidewalls.  The right ovary is almost completely free.  The right fallopian tube is as well.  Unfortunately, at the time of tubal insufflation, the right fallopian tube fairly readily fills but never spills and there is a very thin-walled hydrosalpinx in its distal end.  The left fallopian tube is adhered along with the bottom side of the ovary, which is at the same time completely adhered to the lateral pelvic sidewall.  I am able to free the ovary with blunt and sharp dissection, allowing its distal end to be free.  The ovary was taken down with significant more difficulty.  At this time of tubal insufflation, there is no apparent filling whatsoever along and throughout the left fallopian tube, which I feel is the culprit behind patient’s infertility.   However,  the fallopian tube does appear normal and the fimbriated end is normal as well.  I would not exclude the possibility that the left ovary could in fact be functional but would require a hysterosalpingogram to better determine that.  A distal salpingostomy was performed with multiple small incisions to help simulate the fimbria.  It was somewhat rudimentary, but nonetheless the left tube is free and does lie open spontaneously.

OPERATIVE PROCEDURE:   The patient was placed under appropriate general anesthesia, brought to the Operating Room, identified, placed under appropriate general anesthesia, prepped and draped in the usual fashion in the low-lying dorsal lithotomy position.  A Graves speculum was used to visualize the cervix and an acorn tip was placed inside the cervical canal and secured with the tenaculum for tubal insufflation.  An infraumbilical incision was made.  A 5 mm laparoscopic trocar and sheath was placed into the abdomen, which was insufflated with carbon dioxide under direct visualization.  The left lower quadrant port was made through her previous incision and a 5 mm port with a balloon was placed similarly.  After noting the above described findings, it was apparent that this second port would be necessary and a right lower quadrant 5 mm port was placed without difficulty.  

First of all, the ovarian adhesions on the left side were taken down with blunt and sharp dissection from the lateral pelvic sidewall and the back side of the uterus.  The right fallopian tube was taken off of the ovary.  The right ovary was barely adhered down and was freed up with blunt dissection.  Tubal insufflation was performed with 60 cc of saline and methylene blue to ascertain if there was tubal blockage.  As described above, the right fallopian tube filled but never spilled.  The left fallopian tube did not fill or spill, although the appearance of the left fallopian tube was normal.  Once the tubal insufflation was accomplished, the acorn tip was removed and a Hulka manipulator was placed for better manipulation in the uterus.  Endometrial implants throughout the bladder sidewall and cul-de-sac were individually cauterized with the monopolar hook cautery.  The patient has a large window in the right side of the cul-de-sac.  There are multiple endometrial implants within it.  Cautery was used to fulgurate around the edge of the window shrinking it to about a third of its original size.

The right fallopian tube was grasped near its hydrosalpinx and at this point ultimate fusion was identified and using monopolar cautery and scissors.  A small stab wound was made and then the stellate incisions were made from there by both sharp dissection and a little bit of cautery to control bleeding until the distal end of the right fallopian tube lay free.  At this time, the blue dye readily spilled from the right fallopian tube.  The remainder of the implants on the left side underneath where the ovary was adhered,  were fulgurated.  Once this was accomplished, the pelvis was thoroughly irrigated with about 800 cc of Lactated Ringers.  The pelvis was suctioned free and about 2 g of Arista was placed in the lateral pelvic side wall, mostly behind the left ovary to minimize adhesion formation.  The ports were removed and the CO2 was expelled.  The wounds were closed with 4-0 Vicryl sutures, dressed with 2 x 2's and Opsites.  The patient was awakened and taken to the Recovery Room in good condition.  The estimated blood loss was less than 10 cc.  None was replaced.

CPT Procedure Codes

• 58672  Laparoscopic Fimbrioplasty
• 58673-51 Laparoscopic Salpingostomy
• 58662-51 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
• 58350-59-51 Chromotubation of oviduct

ICD-10cm Diagnosis Codes :

• R10.2 Pelvic and perineal pain
• N97.1 Female infertility of tubal origin
• N80.3 Endometriosis of pelvic peritoneum
• N80.8 Other endometriosis (bladder sidewall
• N73.6 Female pelvic peritoneal adhesions (postinfective)

Operative Report #2

OPERATIVE REPORT: Bilateral vasovasostomy

OPERATIVE DX:  Male Infertility due to vas blockage, inflammation w/ chronic vas pain

OPERATION PERFORMED: Operative vasovasostomy - bilateral

ANESTHESIA: General.

A small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens.  Methelyene blue dye was then injected within the tube denoting the exact area of blockage.  Next the incision was carried down to the area of the inflammation and noted blockage/scarring with complete occlusion of the vas deferens. A towel clip was placed around this. The scarred area was dissected free back to normal vas proximally and distally. Approximately 4 cm of vas was freed up. Next the right vas was amputated above and below the scar tissue. Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends. Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully. After accomplishing this, fluid could be milked from the proximal right vas which was encouraging.

Next the re-anastomosis was performed. Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen. This was all done with 3.5 loupe magnification. Next the right vas ends were pulled together by tying the sutures. A good re-approximation was noted. Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.  Upon the re-anastomosis, methelyne blue dye was again inserted into the tube with no blockages noted.   

There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum. The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.

Next an identical procedure was done on the left side, however, only a partial blockage noted with minimal dye within the tube.  The area of blockage on the left was noted, and excised in the same manner as the right.  

The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition. Antibiotic ointment, fluffs, and a scrotal support were placed.

CPT Procedure Codes

• 55400-50  Vasovasostomy, vasovasorrhaphy  (Mod 50 is appended, as this procedure was performed bilaterally)

ICD-10cm Diagnosis Codes :

• N46.023 Azoospermia due to obstruction of efferent ducts
• R10.2 Pelvic and perineal pain
• N49.1 Inflammatory disorders of spermatic cord, tunica vaginalis and vas deferens

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Coding Wrap Up

As a coder, having good documentation provided to you from your providers, and noted in the medical record  ensures that you are able to clearly code and report the operative session(s), with the diagnosis of infertility and all additional diagnoses that are noted in addition to infertility.    All of these criteria go hand in hand with good quality patient care and correct coding and billing of claims. By working closely with your providers, you can ensure good clean claims, and reduce your overall risk of audit inquiry and financial recoupment of paid claim services.  Always maintain diligence in performing pre-authorization and a targeted reviews of the patients’ insurance policy in regard to infertility testing and procedural correction prior to services being rendered by your physicians.   If the carriers do issue denial, review the denial and take appropriate action such as appeals, and or collection of fees from 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/.