Stress Urinary Incontinence – Surgical Intervention Coding for Urinary Sling

Stress Urinary Incontinence – Surgical Intervention Coding for Urinary Sling

March 2018 

Urinary incontinence is the unintentional loss of urine.  Stress Urinary Incontinence (SUI) is what occurs when there is stress or movement/ activity put upon your bladder.  This activity can be something as minor as laughing, coughing, sneezing, running or lifting.   SUI is not a condition related to “stress” in a psychological way, such as a person who is suffering from a mental anxiety or issue,  SUI is purely related to a movement/activity that is related to a physical stress upon the body. .

There are four main types of urinary incontinence

·         Urge incontinence 

·         Stress incontinence (SUI)

·         Overflow incontinence 

·         Functional incontinence 

Stress urinary incontinence is defined as the unintentional loss of urine caused by the bladder muscle contracting, involuntarily with physical movement.  Some patients also experience a sense of urgency.  SUI is much more common in women than men, however, the most common cause of SUI is a pelvic floor disorder, damage to,  or weakening of the soft tissue that normally supports the urinary organs.

SUI is a direct result of the urinary sphincter muscle that controls the urethra becomes weakened, in addition to the weakening of the soft tissues.  When both the muscle and the soft tissue supports become weak, this allows the release of urine to happen during a “stressful, physical event” such as laughing, coughing, sneezing, etc.

Coding interventions

SUI surgery is not exclusive just to the Urology specialty, many gynecologists also perform surgical intervention for SUI in women.  CPT has given us many code choices for surgical intervention of SUI.  Currently the most commonly used for treatment in both men and women are the surgical procedures for a urinary “sling”. 

When a sling procedure is performed, the surgeon uses the patient's own tissue (or other type of supply)  to essentially “sling up” or “pex up” the uretha by inserting a strip of additional material/tissue to create an additional support system for the urethra.  This support is sewn into the pelvic area to help keep the urethra in the proper physical location. 

Slings can be used for both men and women with SUI. 

Urinary Sling procedures can be performed as an open procedure or as a laparoscopic procedure.  The two most common types of bladder slings are the TOT sling (transobturator tape sling) and the TVT sling (tension-free vaginal tape sling).  The TOT sling and the TVT sling are normally performed as a quick 30 minute, outpatient procedures with a high success rate of nearly 90%. The incisions are small (less than one centimeter) and recovery times are quick.  However, these procedures can be done in coordination with other surgical procedures.

The CPT codes below are those that are specifically related to SUI. 

·         57288 Sling operation for stress incontinence (eg, fascia or synthetic) -  Open Approach

·         57287 Removal or revision of sling for stress incontinence (eg, fascia or synthetic) – Open or laparoscopic Approach

·         53440 Sling Operation for correction of male urinary incontinence (eg, fascia or synthetic) – Open Approach

·         53442 Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) – Open Approach

·         51990 Laparoscopy, surgical; urethral suspension for stress incontinence

·         51992 Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic)

·         10120 Incision and removal of foreign body, subcutaneous tissue – simple

·         10121 Incision and removal of foreign body, subcutaneous tissue - complicated

When coding for these procedures, the coder need to carefully review the operative report to double check if the procedure is being performed laparoscopically or as an open procedure.  The codes for the open approach include the 57287, 57288, 53440 and 53442.  The physician/surgeon may state this is a “mini-laparotomy” however, this still means the surgical approach is “open”.   If the physician documents the procedure was performed with a laparoscope, the codes 51990 and 51992 would be the correct codes to choose.   If the sling is removed laparoscopically, the 57287 is the correct code to use regardless if the procedure was performed as an open procedure or a laparoscopic procedure.

Codes 53440, 53442, 51990, 51992, 57287 and 57288 all have a 90 day global period. Should a sling revision be surgically necessary during the global period, you will need to add modifier -78,  to your code, as this is an unplanned return to the OR for a related procedure.

In addition, revision of an SUI sling procedure code(s)  57287 or 53442 both of these codes  include replacement procedure of a sling (codes 57288 or code 53442) when performed on the same date of service.  These codes are bundled in the CCI bundling edits from CMS, and do not allow a modifier to over-ride the bundling edit. 

The usage of code 10120 and 10121 have become common when physicians have “removed” portions of a mesh erosion that has eroded into the subcutaneous tissues around the abdomen and groin areas.  These integumentary codes are very specific if the mesh is only being removed from the subcutaneous tissue, and not a full excision or revision of the sling itself.  When reporting  CPT code 10120 or 101210 you will need to add either a modifier -58 or modifier -78 if the mesh erosion is treated in the office/procedure room.  The verbiage of codes 10120/10121 strictly denotes in the definition as a removal of foreign body“subcutaneous” tissue. 

Unfortunately, CPT does not give clear guidance as to what constitutes “simple” versus “complicated” when it comes to codes 10120 and 10121.  So if you choose to use CPT Code 10121 (incision and removal of foreign body, subcutaneous tissues; complicated) when an incision is necessary to remove the foreign body you will need to educate the physician to document in the operative note that the removal was “complicated”.   In addition, the physician should also document “why” the removal was complicated, with the usage of additional terms such as; embedded, deep, size, location, abnormality.  It may necessitate having the physician document the amount of time spent in the removal to  support the usage of the “complicated” code 10121, rather than the “simple” code 10120.

Operative Report SPARC suburethal Sling

PROCEDURE:  SPARC suburethral sling

PREOPERATIVE DX: Stress urinary incontinence;  hypermobility of urethra

POSTOPERATIVE DX: Stress urinary incontinence;  hypermobility of urethra.

OPERATIVE PROCEDURE: SPARC suburethral sling.

FINDINGS & INDICATIONS: Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence. Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations. The ureteral orifices were normal bilaterally.

DESCRIPTION OF OPERATIVE PROCEDURE: This patient was brought to the operating room, a general anesthetic was administered. She was placed in dorsal lithotomy position. Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution. She was draped in usual sterile fashion. A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder. Two Allis clamps were placed over the mid urethra. This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution. Two areas suprapubically on either side of midline were injected with the same anesthetic solution. The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra. Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus. The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally. The Foley catheter was removed. A cystoscopy was performed using a 70-degree cystoscope. There was noted to be no violation of the bladder. The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions. The mesh was snugged up against a Mayo scissor held under the mid urethra. The overlying plastic sheaths were removed. The mesh was cut below the surface of the skin. The skin was closed with 4-0 Plain suture. The vaginal vault was closed with a running 2-0 Vicryl stitch. The blood loss was minimal. The patient was awoken and she was brought to recovery in stable condition.

Cpt Code: 

 57288 Sling operation for stress incontinence (eg, fascia or synthetic) -  Open Approach

ICD-10CM :

                N39.3 Stress incontinence (female) (male)

                N36.41 Hypermobility of urethra

Operative Report Male Sling

General anesthesia administered and patient positioned in the dorsal lithotomy position. A 16F Foley catheter placed to drain the bladder. Peri-operative antibiotics are administered.  A vertical incision is made to the perineum approximately 1-2 cm inferior to the penoscrotal junction and carried 1 cm anterior to the rectum. Dissection is continued through Colles' fascia and the underlying bulbocavernous muscle. Sharp dissection is continued until the spongiosal bulb has been freely dissected. The perineal body is identified and dissection is continued proximally approximately 4 cm.

Attention is then focused on identification and marking of the anatomical and landmarks for placement of the surgical passers. The adductor longus tendon is identified and marked, each of the two trochar insertion sites are then marked, and insertion is performed just lateral to the inferior pubic ramus. The skin sites are incised and surgical passer placement is performed.  A surgical finger is placed inside the perineal dissection and to identify the inferior pubic ramus where the passer will exit. Under manual guidance, the passer is advanced through the medial aspect of the obturator foramen, exiting at the level of the perineal body lateral to the spongiosal bulb.  Care is taken to maintain a 45º angle during passage, therefore completing the trochar rotation. The passer is then hooked to the respective sling arm, which is then pulled though the obturator foramen to exit via the skin incision bringing the mesh into place. The mesh is then checked to ensure that twisting has not occurred. Subsequently, the opposite passer is placed in an identical fashion and the sling is pulled into place.

The central mesh anchor is sutured into place, with the posterior aspect fixed to the spongiosal tissue at the most proximal aspect of the bulbar dissection. The distal anchor is then sutured to the spongiosal tissue, each performed with 3-0 vicryl suture.  Tensioning of the sling is now performed, by pulling the mesh arms so the bulb of the corpus spongiosum is brought cephalad by the sling. Sling tensioning is  increased until 3-4 cm of proximal urethral movement is obtained. Bulbar suspension is confirmed by measuring proximal movement from the initial point of fixation to the perineal body.  A cystourethroscopy is then performed to rule out any urethral or bladder injury. The arms of the mesh are cut below skin level and skin incisions closed with Dermabond.  The perineal dissection is then closed with a standard 3-layer closure with absorbable suture.

Cpt Code: 

53440 Sling Operation for correction of male urinary incontinence (eg, fascia or synthetic) – Open Approach

ICD-10CM :

N39.3 Stress incontinence (female) (male)

Operative Report – Laparoscopic removal  

A laparoscopic approach was utilized to remove the polypropylene mesh sling from the retropubic space and , bladder, We entered the peritoneal cavity through the umbilicus and then placed 3 ancillary ports under direct vision .  A 10-mm port is placed in the left paramedian region for suturing, and 5-mm ports are placed suprapubically and in the right paramedian region. After the pneumoperitoneum was created, and adhesiolyis was performed, and taken down, the bladder is filled in a retrograde manner with 200 mL to 300 mL of saline, allowing for identification of the superior border of the bladder edge. Entrance into the space of Retzius was accomplished with a transperitoneal approach using a Harmonic scalpel.  The incision was made approximately 3 cm above the bladder reflection, beginning along the medial border of the right obliterated umbilical ligament. After entering the space of Retzius the pubic ramus was visualized; the bladder drained to prevent injury during dissection. Separation of the loose areolar and fatty layers using blunt dissection develops the retropubic space, and dissection is continued until the retropubic anatomy is clearly visualized. Identification of the sling mesh was made where it touches the pubic rami,  approximately 3 cm lateral from midline.  Once identified, the mesh was grasped and excised from the anterior abdominal wall and then peeled free of the pubic rami periosteum. Dissection was then continued down along the mesh toward the bladder and pubocervical fascia. Extensive scarring was encountered, and the mesh was cut out with the scarred tissue.  In addition, the mesh was eroded into the bladder, and the dissection was continued down to where the mesh appeared to be eroded into the bladder.  The mesh was removed  but erosion was not found to be in the bladder. Dissection was continued down to and through the pubocervical fascia on both sides. An incision was then made suburethrally, and the remaining mesh below the urethra identified, cut in the midline, and freed up allowing removal of the entire portion of the mesh sling.   All laparoscopic surgical devices were removed and accurate sponge and surgical devices accounted for.  Patient then taken to the recovery area, and will be discharged when stable.

Cpt Code: 

                57287 Removal or revision of sling for stress incontinence (eg, fascia or synthetic) – Open or laparoscopic Approach

ICD-10CM :

T83.711D Erosion of implanted vaginal mesh to surrounding organ or tissue; subsequent encounter

Wrap up

The biggest challenge of coding for SUI is ensuring that the correct codes were chosen for either open or laparoscopic approach.  In addition to ensuring that your codes for CPT are correct, but double check your ICD-10cm diagnoses for accuracy.  And with all claims, follow them to ensure that they were submitted in a timely manner, but were also reimbursed correctly.  If not, then file an appeal for readjudication or peer review as necessary.

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/.  

Modifier 22 - A new perspective on a misunderstood modifier

Modifier 22 -  A new perspective on a misunderstood modifier

01/28/2018 -  Lori-Lynne A. Webb

Modifier 22 Increased Procedural Services modifier, as explained in CPT® Appendix A:

“ When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.  Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).” 

Neither CPT, the Centers for Medicare & Medicaid Services (CMS), or even AMA guidelines precisely define the term  “substantially greater” than typically required.  Nor does CPT address the issue that modifier 22 allows a physician to receive a larger reimbursement (usually an extra 20-25%) for an especially difficult or time-consuming procedure.  Unfortunately, 3^rd party payers won’t automatically increase reimbursement for a modifier 22 claim.  It is common for  physicians to increase their fee by 20-25% when submitting a claim with the modifier 22 attached to compensate the provider for the “over and above” work that was performed on the case.  CPT does not specify “financial compensation” in the modifier definition. 

However, in getting modifier 22 claims paid ; overall the case will require more than just extra work in the operating room; it also means clear and concise clinical documentation to support the “additional work performed” to be noted by the provider.  As the coder, you have a responsibility to ensure the claim submission went through correctly; and you have followed the claim through to ensure it was paid by the carrier  with the additional revenue.  If your claim was not paid correctly, it will be up to you to formulate an appeal back to the carrier for the additional reimbursement you have asked for . 

When to use Modifier 22

Modifier 22 Increased Procedural Services;  is to be used only for services/procedures  which are greater than usual and which requires increased physician work above and beyond normal.   When it comes to a “normal” procedure, the definition of “above and beyond” normal is very vague and can be interpreted in a multitude of ways by the 3^rd party payers.

Specific circumstances that may support modifier 22 include:

·         Excessive/unexpected blood loss or hemorrhage relative to the procedure

·         Presence of an excessively large surgical specimen(especially in abdominal surgery)

·         Trauma that is extensive enough to complicate the particular procedure. (and that cannot be billed with additional procedure codes or with an unlisted procedure code)  

·         Abnormal and/or other pathology, tumors, malformations that interfere directly with the surgery

·         Procedures that are significantly more complex than described in CPT 9and cannot be billed with additional procedure codes and/or an unlisted procedure code)

·         Morbid obesity and

·         Altered anatomy such as severe scarring or adhesions from previous trauma.

·         Patient complications during complex surgery such as converting a laparoscopic procedure to an open approach; patient hemorrhage during surgery; or unexpected operative complications during surgery.  

·         Complex delivery/birth  (eg twins, excessive hemorrhage, fetal or maternal distress)

Modifier 22 usage with global maternity care, or maternal services may be appropriate if:

• Management of pregnancy related complications (pre-eclampsia, preterm labor, bleeding, etc…) has required greater than 15 antepartum visits.
• For cesarean delivery of multiple gestations.
• The cesarean delivery requires substantial additional work.

However, with usage in obstetric services, the 3^rd party payers may have restrictions or specified criteria to be followed when submitting obstetric service claims with a modifier 22.  CMS/Medicare/Medicaid have not specifically addressed usage of this modifier with claims.  American Congress of Obstetricians and Gynecologists have noted that modifier 22 can be used for 3^rd and 4^th degree lacerations that occur at the time of delivery. 

In Appendix A of the CPT book, the definition also includes a “note”  that informs us that modifier -22 should not be appended to an E/M service.  This information implies that modifier 22 should only be used along with valid procedure/surgery CPT codes. According to the Medicare Physician Fee Schedule Database, modifier 22 can be appended to procedures having a global surgery indicator of 000, 010, or 090 post operative days.  Modifier -22 is not valid for “XXX” global period indicators, which includes E/M, radiology, laboratory, pathology, and most medicine codes.  With some 3^rd party payers, procedure codes with global day indicator of ZZZ, or MMM in addition of modifier 22 upon those claims may be considered upon review.

Clinical Documentation

The clinical documentation provided in the patients’ operative record is crucial to substantiate usage of modifier 22.  A clear and concise description of the unusual circumstance(s) that outline why this particular encounter required greater effort, than the normal services, should be well documented by the provider.   

When documenting in the operative/procedural record avoid using a generalized statement. Comments like "patient was obese" or "surgery took longer than usual" or "multiple adhesions" lack specificity to truly detail why the procedure was beyond the normal or routine type difficulties that are encountered with the procedure on a day to day basis.  The surgeon should explain and identify any additional acute or chronic illnesses, and/or preexisting conditions, or complications that were encountered within the surgery that contributed to warrant extra time effort and the usage of modifier 22. 

Communicate with the provider to use “comparative” verbiage to show how this procedure was significantly different from the typical and or average procedure.  For example, a statement such as “The patient lost 850 cc’s of blood during the delivery with extensive clotting, hemorrhage and uterine atony. Normal blood loss is approximately 200 cc’s”.  The provider should also denote any and all additional procedures that were performed to control the hemorrhage during the delivery. ( eg. postpartum curettage, application of a Bakri-Balloon or hemabate)   If the original clinical documentation does not support the usage of the modifier 22 prior to the claim being submitted, ask the provider to amend or re-document the surgery to accurately reflect the complexity of the surgery that necessitates the usage of the modifier 22. 

When using time as a modifier 22 criteria, comparative verbiage is also helpful, such as stating “I spent 2 hours of abdominal adhesiolysis due to the patient’s morbid obesity before gaining access to the operative field.  Normal time for adhesiolysis for this surgery is usually 20-30 minutes. Other good clinical examples are “Due to the altered anatomical issues and scarring from  previous abdominal surgeries;  upon entrance to the abdominal cavity, we had to delicately lyse colonic adhesions from the abdominal and peritoneal area for over an hour to obtain access into the surgical field, whereas, this normally takes 5-10 minutes.”  Or “We had to make four attempts to place the guide wire due to extensive plaque buildup prior to the start of the catheterization.”

Claims Submission

Unfortunately, many 3^rd party payers automatically reject or refuse any claims that have a modifier 22 appended to them upon initial electronic claim submission.  Once this rejection has been received back to the provider, you will need to submit the procedure/operative report documents to support your claim for payment of additional revenue for modifier 22claims.  In addition, be prepared to submit the operative notes and a separate statement or letter indicating how the procedure was significantly more difficult that the normal surgical procedure.  You may also want to consider adding a notation within the separate statement asking for the additional 20-25% more reimbursement for the additional work performed.  Last but not least, if the 3^rd party payer refuses to consider your claim upon the submission of the additional information, appeal to the highest level possible, up to and including a peer to peer physician review with physicians that practice within the same specialty. 

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/

Understanding Coding of Hypertension in Pregnancy

Understanding Coding of Hypertension in Pregnancy

Saturday, June 23, 2018

Hypertension in pregnancy still remains as one of the most misunderstood complications of pregnancy, in addition to the incorrect usage of the ICD-10 diagnosis codes that go with it.   ICD-10cm has a specific block of codes allocated to Pregnancy and hypertension, that should be used with all pregnancy coding.  These codes denote a pre-existing hypertention and then the gestational or pregnancy-induced hypertension.

ICD-10cm Code block Group

·         O10  Pre-existing hypertension complicating pregnancy, childbirth and the puerperium

·         O11  Pre-existing hypertension with pre-eclampsia

·         O12  Gestational [pregnancy-induced] edema and proteinuria without hypertension

·         O13  Gestational [pregnancy-induced] hypertension without significant proteinuria

·         O14  Pre-eclampsia

·         O15  Eclampsia

·         O16  Unspecified maternal hypertension

As you can see from the list above, there are numerous codes to choose from.  As coders, we rely on our physicians to give us good clinical documentation within the pregnancy record, so we can code and bill appropriately for their services.  As in the case of a pregnancy that the OB is supervising, the added diagnosis of Hypertension in pregnancy brings added risk factors to that pregnancy oversight.  We also need to add ICD-10cm code for a high risk pregnancy due to hypertension.  The pregnancy supervision code for high risk pregnancy will be coded as the primary code based upon the ICD-10cm guidelines.   ICD-10cm coding guidelines for high-risk pregnancy changed in 2017. The current rule from the 2018 ICD-10-CM Official Guidelines for Coding and Reporting (effective Oct 1, 2017 – Sept 30, 2018) is below:

Supervision of High-Risk Pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 58 of 117) Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery.  

For routine prenatal outpatient visits for patients with high-risk pregnancies, a code from category O09, Supervision of high-risk pregnancy, should be used as the first-listed diagnosis..  

The high risk supervision codes noted below, do not have a category specifically for oversight of hypertension in pregnancy, however this is something that we need to have coded for our diagnoses.  If we are going to add a high risk pregnancy diagnosis to our record, the code choice of O09.89 would the best choice, as the hypertension in pregnancy is in the “other high risk” category and our provided has specified it as such. 

 O09 Supervision of high risk pregnancy

·          O09.0 Supervision of pregnancy with history of infertility

·          O09.1 Supervision of pregnancy with history of ectopic pregnancy

·          O09.A Supervision of pregnancy with history of molar pregnancy

·          O09.2 Supervision of pregnancy with other poor reproductive or obstetric history

o    O09.21 Supervision of pregnancy with history of pre-term labor

o    O09.29 Supervision of pregnancy with other poor reproductive or obstetric history 

·          O09.3 Supervision of pregnancy with insufficient antenatal care

·          O09.4 Supervision of pregnancy with grand multiparity 

·          O09.5 Supervision of elderly primigravida and multigravida

o    O09.51 Supervision of elderly primigravida 

o    O09.52 Supervision of elderly multigravida 

·          O09.6 Supervision of young primigravida and multigravida

o    O09.61 Supervision of young primigravida

o    O09.62 Supervision of young multigravida

·          O09.7 Supervision of high risk pregnancy due to social problems

·          O09.8 Supervision of other high risk pregnancies

o    O09.81 Supervision of pregnancy resulting from assisted reproductive technology

o    O09.82 Supervision of pregnancy with history of in utero procedure during previous pregnancy

o    O09.89 Supervision of other high risk pregnancies

·          O09.9 Supervision of high risk pregnancy, unspecified

In some cases, the high blood pressure diagnosis is present prior to the pregnancy,  however, the patient can develop high blood pressure during pregnancy, which would then be noted as gestational hypertension.   

Ø  Chronic hypertension is high blood pressure that was present before pregnancy or that occurs before 20 weeks of pregnancy. But because high blood pressure usually doesn't have symptoms, the provider may be reluctant to state this as a chronic condition, as this may or may not have been noted as a diagnosis for the patient by a previous provider or prior to the pregnancy.

Ø  Chronic hypertension with superimposed preeclampsia is condition that can also occur in women with chronic hypertension before pregnancy who develop worsening high blood pressure and protein in the urine or other blood pressure related complications during pregnancy.

Ø  Gestational hypertension is the patient noted in the record to have high blood pressure that develops after 20 weeks of pregnancy. Normally there is no excess protein noted in the urine or other signs of organ damage however, some women with gestational hypertension may develop preeclampsia.

Ø  Preeclampsia occurs when hypertension develops after 20 weeks of pregnancy, and is associated with signs of damage to other organ systems, including the kidneys, liver, blood and/or brain. Untreated preeclampsia can lead to serious complications for mother and baby, including development of seizures which then the diagnosis becomes eclampsia.

o   Previously, preeclampsia was clinically diagnosed only if a pregnant woman had high blood pressure and protein in her urine. However, it has been noted that it's possible for the patient to have preeclampsia without having protein in the urine.

Ø  Eclampsia is the onset of seizures (convulsions) in a woman with pre-eclampsia.  The onset may be before, during, or after delivery, but it can be diagnosed and treated  during the second trimester in the  pregnancy.

o   The seizures are usually the  tonic–clonic type and typically last between 30 and 60 seconds.  Complications of eclampsia include aspiration pneumonia, cerebral hemorrhage, kidney failure, and cardiac arrest

Ø  HELLP Syndrome is another variant of pre-eclampsia and/or eclampsia  as a known pregnancy complication. HELLP syndrome is characterized as hemolysis, elevated liver enzymes, and  low platelet count.  HELLP syndrome can be fatal to both the mother and the fetus. 

The clinical documentation of consistent pregnancy blood pressure is an important part of the patients’ prenatal care. The list below designates the levels at which the blood pressures should be noted.  As a coder, if you are not seeing these designations, you will want to query the provider and ensure if the patient has a true “hypertension” or simply an elevated blood pressure.  This will make a difference in your code choice.  This will also determine if the ob visit should be considered part of the prenatal care/OB package, or if it should be billed as a separately identifiable visit outside of the prenatal care/OB package.

o   Elevated blood pressure:  Elevated blood pressure is a systolic pressure ranging from 120 to 129 millimeters of mercury (mm Hg) and a diastolic pressure below 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control blood pressure.

o   Stage 1 hypertension: Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.

o   Stage 2 hypertension: More severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

NOTE:  After 20 weeks of pregnancy, blood pressures that exceeds 140/90 mm HG — documented on two or more occasions within the prenatal record, that are at least four hours apart, without any other organ damage — is considered to be gestational hypertension. 

As we look to the ICD-10cm coding guidelines, the pre-existing condition (such as hypertension) should be considered carefully. 

Pre-existing conditions versus conditions due to the pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 59 of 117)

Certain categories in Chapter 15 distinguish between conditions of the mother that existed prior to pregnancy (pre-existing) and those that are a direct result of pregnancy. When assigning codes from Chapter 15, it is important to assess if a condition was pre-existing prior to pregnancy or developed during or due to the pregnancy in order to assign the correct code.

Categories that do not distinguish between pre-existing and pregnancy-related conditions may be used for either. It is acceptable to use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter. 

The ICD-10cm guidelines also go on to say that the “O” codes that have been set forth for hypertension in pregnancy also include the codes for hypertensive chronic kidney disease.  If this is the case we are then to assign not only the appropriate O10 code, but also add an additional code from the appropriate hypertension category from ICD_10cm Chapter 9: Diseases of the Circulatory System (I00-I99) and specify the type of heart failure or CKD.

Pre-existing hypertension in pregnancy (ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 60 of 117)

Category O10, Pre-existing hypertension complicating pregnancy, childbirth and the puerperium, includes codes for hypertensive heart and hypertensive chronic kidney disease. When assigning one of the O10 codes that includes hypertensive heart disease or hypertensive chronic kidney disease, it is necessary to add a secondary code from the appropriate hypertension category to specify the type of heart failure or chronic kidney disease. See Section I.C.9. Hypertension

Office Coding Scenario – Admission to L&D:

Patient is a 32 year old who has come in at the request of our Triage RN status post patient call 1 hr ago. Pt is G2 and P1 at 35 and 3/7 weeks with gestational hypertension stable on labeletol. Pt arrived 20 minutes ago and is now complaining of a severe headache, leg swelling, blurred vision, abdominal pains, and a BP of 170/102.   She notes baby is moving well, but is having contractions.  Her husband is present with her and is very supportive, but concerned.  Sarah has a history of mild pre-eclampsia with her first child who delivered vaginally 2 years ago. She is allergic to PCN with a bad rash noted 4 years ago. Her Blood pressure in the clinic 2 days ago was 140/85.. She was not started on any new medications, nor any changes to her current Labeletal dose,  but was put on bedrest.   She continues to complain of a severe headache.  She is oriented x3, but somewhat sleepy. She has pitting edema bilaterally at a 3+  She has also complained of some mild nausea with no vomiting at this point. No complaints of shortness of breath. Lungs are still clear. She continues to complain of upper abdominal pain. Her urine dip indicated some mild 2+ proteinuria.  Her most recent vital signs are BP158/98, P98 R14, T98.6 .   She has current symptoms of severe pre-eclampsia, with pre-term labor and trending toward eclampsia.  At this time, I will send orders for direct admission to L&D Observation for continued surveillance of severe pre-eclampsia.  Patient directed to L&D.  I will follow with patient at evening rounds.

Coding Considerations:

ICD-10 cm Diagnosis:

O09.89 Supervision of other high risk pregnancies

O14.13 Severe pre-eclampsia third trimester
O60.03 Preterm labor without delivery
Z3A.37 37 weeks gestation of pregnancy

According to the CPT Maternity Care and Delivery guidelines that are noted at the beginning of the maternity care section within the CPT book it clearly states

“Medical complications of pregnancy; (eg cardiac problems, neurological problems, diabetes, hypertension, toxemia, hyperemesis, preterm labor, premature rupture of membranes,trauma) and medical problems complicating labor and delivery management may require additional resources and may be reported separately.” 

Billing/Reimbursement Issues

Some 3^rd party payers may consider the above scenario of care as part of the OB package of care, and not reimburse for the admission to observation as a separately identifiable service outside of the OB package.  If that is the case, CPT does allow for this and you should code, bill and subsequently appeal for your appropriate payment of such. 

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