Finding clarity in coding of fetal status

Finding clarity in coding of fetal status

Lori-Lynne A. Webb

February 27, 2015

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

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

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

656.31 Fetal distress affecting management of mother – Delivered

656.33 Fetal distress affecting management of mother – Antepartum

656.3X Excludes:

abnormal fetal acid-base balance (656.8x)

abnormality in fetal heart rate or rhythm (659.7x)

fetal bradycardia (659.7x)

fetal tachycardia (659.7x)

meconium in liquor (656.8x)

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

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

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

Fetal acidemia complicating labor and delivery

Fetal acidosis complicating labor and delivery

Fetal alkalosis complicating labor and delivery

Fetal metabolic acidemia complicating labor and delivery

Excludes1:

Fetal stress NOS (O77.9)

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

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

Excludes2:

Abnormality in fetal heart rate or rhythm (O76)

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

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

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

o   Nonreassuring FHR patterns

o   Fetal tachycardia

o   Fetal bradycardia

o   Saltatory variability

o   Variable decelerations associated with a non-reassuring pattern

o   Late decelerations with preserved beat-to-beat variability

o   Ominous patterns

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

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

Category I : Normal.

The fetal heart rate tracing shows ALL of the following:

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

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

Category II : Indeterminate.

The fetal heart rate tracing shows ANY of the following:

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

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

Category III: Abnormal.

The fetal heart rate tracing shows EITHER of the following:

Sinusoidal pattern OR absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia.

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

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

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

Fetal bradycardia complicating labor and delivery

Fetal heart rate decelerations complicating labor and delivery

Fetal heart rate irregularity complicating labor and delivery

Fetal heart rate abnormal variability complicating labor and delivery

Fetal tachycardia complicating labor and delivery

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

Excludes1:       fetal stress NOS (O77.9)

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

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

Excludes2:       fetal metabolic acidemia (O68)

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

O77 Other fetal stress complicating labor and delivery

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

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

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

Labor and delivery complicated by electrocardiographic evidence of fetal stress

Labor and delivery complicated by ultrasonic evidence of fetal stress

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

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

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

       abnormality in fetal heart rate or rhythm (O76)

       fetal metabolic acidemia (O68)

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

Example #1

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

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

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

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

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

ICD-9 Diagnoses:

644.03    Threatened premature labor prior to 37 weeks

659.63  Elderly multigravida, with antepartum condition or complication

642.33  Transient hypertension of pregnancy, antepartum

ICD-10 Diagnoses:

O60.03  Preterm labor without delivery, third trimester

O09.523 Supervision of elderly multigravida, third trimester

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

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

Example #2

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

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

Afebrile. Normotensive. Lungs: CTAB  CV:RRR

Abd: +BS. No guarding or rebound.

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

Ext: No cords.

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

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

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

ICD-9 Diagnoses:

644.03             Threatened premature labor prior to 37 weeks

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

ICD-10 Diagnoses:

O60.03                        Preterm labor without delivery, third trimester

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

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

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

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

Taxonomy Codes – A quick code-set refresher

April 9, 2015

Taxonomy Codes – A quick code-set refresher

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

What is a taxonomy code? 

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

·         Individuals/Groups of Individuals

·         Non-Individuals

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

Ø  Level 1, provider type:

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

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

Ø  Level 2, classification:

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

·         Acute Care

·         Adult Health

·         Emergency

·         Neonatal

·         Pediatrics

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

§  Ambulatory surgery center

§  Birthing Center

§  Critical Access Hospital

§  Home Infusion

§  Foster Care

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

§  Diabetes Educator

§  Gerontology

§  Obstetric High-Risk

§  Oncology

§  Ambulatory Care

§  Orthopedic

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

§  Children’s’ Hospital

§  Critical Access Hospital

§  Rural Hospital

§  Women’s Hospital

Taxonomy Code Structure

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

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

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

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

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

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

Taxonomy Code Updates

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

Billing Claim Submissions:

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

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

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

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

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

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

Interrupted Pregnancy:  Tubal, Ectopic, and other Abnormal Pregnancies

04.26.2015 -  Lori-Lynne Webb 

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

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

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

·         Abdominal Pregnancy

·         Tubal Pregnancy

·         Ectopic Pregnancy

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

·         Cervical

·         Ovarian

·         Ampullary

·         Cornual

o   Interstitial

·         Isthmic

·         Fimbrial

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

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

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

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

Coding for Abnormal Pregnancy Diagnosis and Surgical Procedures

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

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

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

Ø  59130 Surgical treatment of ectopic pregnancy; abdominal pregnancy

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

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

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

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

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

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

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

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

633 Ectopic pregnancy

·         633.00 Abdominal pregnancy without intrauterine pregnancy

·         633.01 Abdominal pregnancy with intrauterine pregnancy

·         633.10 Tubal pregnancy without intrauterine pregnancy

·         633.11 Tubal pregnancy with intrauterine pregnancy

·         633.20 Ovarian pregnancy without intrauterine pregnancy

·         633.21 Ovarian pregnancy with intrauterine pregnancy

·         633.80 Other ectopic pregnancy without intrauterine pregnancy

·         633.81 Other ectopic pregnancy with intrauterine pregnancy

·         633.90 Unspecified ectopic pregnancy without intrauterine pregnancy

·         633.91 Unspecified ectopic pregnancy with intrauterine pregnancy

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

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

Ectopic pregnancy

·         O00.0 Abdominal pregnancy

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

·         O00.1 Tubal pregnancy

o   Fallopian pregnancy

o   Rupture of (fallopian) tube due to pregnancy

o   Tubal abortion

·         O00.2 Ovarian pregnancy

·         O00.8 Other ectopic pregnancy

o   Cervical pregnancy

o   Cornual pregnancy

o   Intralegamentous pregnancy

o   Mural pregnancy

·         O00.9 Ectopic pregnancy, unspecified

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

Operative Cases -  applying your knowledge

Case #1:

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

CPT procedure:

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

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

ICD-10cm: O00.1 Tubal pregnancy  

Case #2

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

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

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

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

CPT procedure:

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

                                 

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

ICD-10cm: O00.1 Tubal pregnancy  

Case #3

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

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

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

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

CPT Procedure:

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

ICD-9:  633.10 Tubal pregnancy without intrauterine pregnancy

256.4   Polycystic ovaries

ICD-10cm:       O00.1 Tubal pregnancy  

E28.2 Polycystic ovarian syndrome

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/.