Breast Care and Screening – 2015: Coding & Documentation Strategies

Breast Care and Screening – 2015:  Coding & Documentation  Strategies

October is Breast Cancer awareness month.  In this month, physicians and healthcare professionals have heightened the awareness of patients' to be screened for all types of breast care conditions and breast cancers. 

Breast cancer afflicts both men and women.  ICD-10cm diagnosis codes now recognize and give us the specificity for location, but also designation between men and women.  All of the breast cancer neoplasm codes can be found in ICD-10 under the C-50 codeset.   But what about screening?  ICD10cm has screening codes for usage with mammogram too.

Z12.31 Encounter for screening mammogram for malignant neoplasm of breast, and

Z12.39 Encounter for other screening for malignant neoplasm of breast.

The Mammogram procedure has been performed for a number of years, and CMS has had strict policies on how it is to be paid.  Not only does CPT have Mammography codes, but HCPCS also has 3 codes to be utilized for mammography also.  In 2015 CPT gave us codes for digital breast tomosynthesis which provides higher diagnostic accuracy compared ton conventional mammography.  The usage of Screening breast tomosynthesis offers better detection of abnormalities with a minor increase in the radiation exposure to the breast tissue.  The breast tomosynthesis is routinely used for high resolution, limited angle in the clinical application of breast imaging.   It is somewhat similar in the view as a CT type of scan (computerized tomography)

With the inclusion of the new CPT Tomosynthesis codes, these ne CPT codes must be billed in conjunction with the screening mammography HCPCS codes for Medicare.  This includes all 2D imaging and 3D imaging.  Medicare is also particular that a "screening" diagnosis code be used on these claims and not a diagnostic/problem focused diagnosis.  

Prior to October 1^st we were instructed to use only the ICD-9 codes. However, since ICD-10cm is now the valid code-set we need to be using ICD-10cm code Z12.31 or Z12.39 with the appropriate procedure codes.

2015 CPT Codes:

·         77055 Breast Mammography – Diagnostic Unilateral

·         77056 Breast Mammography – Diagnostic Bilateral

·         77057 Breast Mammography Screening Bilateral 

·         77061 Digital Breast Tomosynthesis; unilateral

·         77062 Digital Breast Tomosynthesis; bilateral

·         +77063 Screening digital Breast Tomosynthesis   (add-on code)

·         77058 Breast MRI Imaging Mammography

·         77059 Breast MRI Imaging Bilateral Mammography

·         76641 Breast Ultrasound Unilateral real time with image documentation complete

·         76642 Breast Ultrasound limited

2015 HPCPS Codes

·         G0202 Screening mammography, producing direct digital image, bilateral, all views

·         G0204 Diagnostic mammography, producing direct 2-d digital image, bilateral, all views

·         G0206 Diagnostic mammography, producing direct 2-d digital image, unilateral, all views

As of August 2012, Medicare will now cover screening mammography depending on the age of the female patient, however, Medicare does not cover screening mammography for men. 

Women younger than age 35	No Medicare payment allowed for Screening Mammography
Women Aged 35 – 39 years	Baseline Mammogram – Medicare will only pay for one screening for women in this age group
Women Aged 40 and older	Annual Mammogram (or at least 11 months after the last covered screening mammography)

If the patient is determined to need a Medically necessary/diagnostic  mammogram, those will be covered as often as deemed medically necessary.  Medicare has also put forth an update to the guidelines in helping to distinguish when diagnostic mammography is a covered test.  This information was published in June, 2015  in the Medicare claims processing manual.   This information is noted as below:

Diagnostic Mammography

A diagnostic mammography is a radiological mammogram and is a covered diagnostic test under the following conditions:

• A patient has distinct signs and symptoms for which a mammogram is indicated;

• A patient has a history of breast cancer; or

• A patient is asymptomatic, but based on the patient’s history and other factors the physician considers significant, the physician’s judgment is that a mammogram is appropriate.

Medicare also requires us to add the new modifier "GG".  This modifier allows the patient to have a screening mammogram and a diagnostic mammogram on the same day.  If the patient is having a  screening mammogram performed, but the radiologist determines a need for a diagnostic mammogram on the same day, Medicare will pay for both services if we add the modifier GG.

In regard to commercial payers, the new digital breast tomosynthesis codes may be considered "experimental" or "investigational" and not be covered for breast cancer screening.   As a coder, an inquiry to the carrier should be part of your process if unsure if a specific 3^rd party payer may not pay for this service.  

Tips & Strategies for diagnosis coding in ICD-10cm

Now that we are fully engaged in coding for ICD-10cm, we are instructed to use the screening code of Z12.31 (encounter for screening mammogram for malignant neoplasm of breast).  In addition iif the patient also has a family history of breast cancer, the Z80.3 family history diagnosis should also be appended to your claim. 

When we are coding for a diagnostic mammogram, the screening code of Z12.31 or Z12.39 should never be used in our claims.  The signs and symptoms reported in the notes would normally be coded as a priority.  However, the claim can be held until the mammography interpretation has been completed by the radiologist, and the coding should be representative of what was noted within the radiologist notes.    If the exam is "normal" or "inconclusive"  then the coder should still code based upon any signs and/or symptoms noted. (eg. Breast pain).  If the radiologist notes a definitive diagnosis such as breast calcifications, then the codes from the R92 code-set should be used.

R92 Abnormal and inconclusive findings on diagnostic imaging of breast

·         R92.0 Mammographic microcalcification found on diagnostic imaging of breast

·         R92.1 Mammographic calcification found on diagnostic imaging of breast

·         R92.2 Inconclusive mammogram

·         R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast

Coding of a breast neoplasm based upon mammography should only be done if the patient has a neoplasm that is documented by the radiologist in the radiology interpretation.  Coders should not make an "assumptive" leap to code from the C50 code-set, unless specifically noted by the radiologist.

Coding of mammography for female patients that have breast implants also can be confusing.   If a patient is having a screening mammogram and also has breast implants, then the Z12.31 will be coded as the primary code, and the code Z98.82 which denotes that the patient currently has breast implants.  If the patient is currently having a mammogram due to a problem with their implants, then a complication code, or symptom code would be the diagnosis driver for a diagnostic mammogram, and not a screening mammogram.  If the patient had breast implants previously, and has had them removed, the Z98.82 implant status code is no longer valid.  ICD-10cm gives us code Z98.86 which informs that the patient has a personal history of breast implant removal.

Breast MRI and Breast Ultrasound

Breast MRI and breast ultrasound codes are not normally used for screening type of services.  These methods of imaging are for diagnostic review and for determining a more definitive diagnosis in patients with abnormal mammogram services.

Most Breast MRI services are performed for patients that have dense breasts or are at high risk for breast cancer.  Some breast MRI's are performed with a breast lump, that does not show up on traditional mammogram, but can be felt/palpated by the provider.  The usage of breast MRI has also been done for patients with breast implants, to avoid the possibility of an implant rupture during traditional mammography.

In 2015 CPT did create new codes for breast ultrasound.  The breast ultrasound codes denoted a unilateral "complete" exam and a unilateral "limited" exam.  CPT code 76641 breast ultrasound complete, the clinical documentation needs to include the examination of all four quadrants of the breast and regroareolar region.  If less than the above was performed, then the limited breast ultrasound code 76642 should be reported.  If both breasts have been imaged, as a coder, you have the option to either append the "50" bilateral modifier, or  usage of the "rt" and "lt" modifiers for each breast.  If you are unsure which to append, contact the 3^rd party insurance payer and request guidance of how they prefer the claims to be coded.  Medicare covers breast MRI when clinically indicated and medically necessary.  The list below is not an all inclusive list, but ones that Medicare has deemed as a "diagnostic" indicator for usage of breast MRI.

Ø  Pain in breast

Ø  Lump/mass in breast

Ø  Other specified breast disorder

Ø  Unspecified breast disorder

Ø  Symptoms breast discharge-other

Ø  Breast Cancer (NOS)

Ø  Breast neoplasm\uncertain behavior

Ø  Fibrocystic breast disease

Ø  Cystic breast

Ø  Hypertrophy breast

Ø  Inflammation disease of breast

Ø  Mechanical complication of Prosthetic Device/Breast Implant

Clinical Case Study – Clinical Documentation

Case #1

A 39 year old woman with a family history of breast cancer in her sister (who is age 40) has a bilateral mammogram that reveals breast tissue with no suspicious findings.   Patient is at increased risk for breast CA due to her family history.  Radiologist recommends additional screening test of a breast MRI. 

Coding consideration:

CPT: 77057 Screening mammogram   ICD-10:  Z12.31 screening mammogram

Case #2

A 39 year old woman with a family history of breast cancer in her sister (who is age 40) has a bilateral mammogram that reveals very dense breast tissue with suspicious findings on the left breast.   Patient is at increased risk for breast CA due to her family history.  Radiologist recommends additional views lt breast mammogram and a breast MRI on the left breast.  All are performed same day.

Coding consideration

CPT 77057.GG screening mammogram bilateral   ICD-10: Z12.31

CPT 77055.LT diagnostic mammogram   ICD-10: R92.2

CPT 77058.LT breast MRI  ICD-10cm R92.2

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/.  

Q&A part 2 (Unbundling the global pregnancy package)

Q&A – from Webinar (Part 2)

2.1  Q:  Is billing an e/m along with a 0501F code on an initial OB appointment when the confirmation of pregnancy is done at the same appointment allowed?   If not what ways other than servicing the patient at two separate appointments can we be reimbursed for both the initial (global) and the confirmatory appointment?

2.1.1 Q .When a new patient comes to the office with symptoms of pregnancy but doesn't know that she's pregnant and a test determines that she is pregnant does that 1st visit billable or is it part of the global package?

2.1/2.1.1  A:   As per the American Congress of Obstetricians and Gynecologists (ACOG)  guidelines in which most OB practices try to follow, ACOG presented information (see below) as their recommendation when reporting the confirmation of the first pregnancy visit

“The initial OB visit may be reported as an E/M service under certain conditions.  Even if the patient has taken a home pregnancy test, the initial visit may still be billed as an E/M service as you will be officially confirming the pregnancy.

When coding for the “initial ob visit”, there are a few things that have to be taken into consideration.  First you have to determine if the patient is there for a confirmation of pregnancy or if the pregnancy has already been confirmed.  The second thing that needs to be determined is if the OB record has been initiated.  Once this has been established you can determine how the visit should be reported. “http://www.acog.org/About-ACOG/ACOG-Departments/Coding/Reporting-the-Confirmation-of-Pregnancy-Visit

The above information was taken directly from the ACOG web site.  However, in my opinion regarding the billing of the E&M along with the designation of the Category II Code 0501F for the initial OB appointment.  I consider the “OB start antenatal”  at the time the OB flow sheet is initiated, and the physician is performing the comprehensive intake and evaluation process for a new OB patient.    This process is certainly separately identifiable from simply “confirming” the pregnancy.    A pregnancy confirmation visit would normally be a very short and quick E&M visit, then the patient scheduled at a later date to begin the OB intake and flow sheet process which would include the comprehensive history, exam and plan of care for the current pregnancy.

In my opinion, I would have it clearly defined that the OB “confirmation” of pregnancy is documented as clearly defined/separately identifiable from the “Ob start antenatal” if your office practice chooses to bill for the E&M, and begin the evaluation/OB flow sheet at the same encounter.

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2.2 Q: On a delivery account, would you code RH immunization on the mother's chart if she is given Rhogam during the pregnancy but not at the delivery because baby is also RH negative?

2.2 A:  A couple of years back I looked at this issue and from a clinical standpoint, the Rh factor of positive and negative can lead to problems between a mother and the developing fetus.  It is commonly referred to as mother-fetus incompatibility, and occurs when the mother is Rh-(negative) and the fetus is Rh+(positive).   To help prevent these complications during pregnancy,  physicians routinely order the pregnant patient to undergo testing to determine the Rh and ABO blood typing.  Once this has been completed, the physician will then determine if having the patient receive the Rho(D) immune globulin.

As for the clinical documentation to be recorded in the chart, if the physician suspects and initiates the RH immunization during the pregnancy it is assumed that the patient and fetus have the incompatibility.  However, if this is not the case at the time of delivery, then the provider should notate this finding at that time.  However, according to the American Congress of Obstetricians and Gynecologists (ACOG) they have developed a standard guideline of re-administration of the Rho(D) immune globulin product

These standards are:

·         The first dose of Rho(D) immune globulin is to be given at 28 weeks’ gestation (earlier if there’s been an invasive event),

·         Followed by a postpartum dose given within 72 hours of delivery.

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2.3 Q: With the prenatal visits and the delivery as separate from the OB package you would always append the -59 to the delivery? My understanding is the -59 is used only for procedure to procedure?

2.3 A:  The modifier 59 should not be appended to the code(s) when an “unbundled” delivery is billed for at the same time the charges for the antepartum services are billed.  In addition,  these two services should be billed on two separate claims, identifying the first claim as antepartum services only denoting the span dates you saw the patient.  The billing of the delivery should then be on a separate claim showing the “delivery only” as unbundled and dated as the actual date of delivery. 

On your claim information note line, you should denote “antepartum care only” and the usage of the codes 59425/59426 or E&M visits denoting the antepartum care.   Within the defined parameters of CPT’s definition of modifier 59 there is critical verbiage that I have highlighted below that refers to those services “not ordinarily encountered or performed on the same day by the same individual.  The antepartum care and the delivery would not fulfill this parameter for modifier 59.

Rationale: The 2015 CPT Manual defines modifier 59 as follows:

“Distinct Procedural Service: Under certain circumstances, it may be necessary to

indicate that a procedure or service was distinct or independent from other non-E/M

services performed on the same day. Modifier 59 is used to identify

procedures/services, other than E/M services, that are not normally reported

together, but are appropriate under the circumstances.

Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the Same individual. However, when another already established modifier is appropriate,  it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

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2.4 Q:  Are we able to bill an E&M visit if a pap was performed at the post-partum appointment?

2.4 A:  In a normal post-partum service visit(s) as part of the global package, a pap smear is commonly performed as  ‘routine’ testing during the post-partum period, and the “cervical pap scraping” or procurement procedure performed by the physician/midwife is bundled into the postpartum visit.  However, the pap-test itself (e.g. 88175)  would be billable.

If the “Pap scraping” is being performed during the postpartum period is a part of a separately identifiable workup for a problem (not pregnancy/postpartum related)  then an E&M would be billable and the procurement of the scraping is bundled into the E&M service.   A modifier 24 would also need appended as an E&M service provided during a post-op time frame. 

Rationale:  According to the postpartum care guidelines put forth by CPT and ACOG this is what is normally provided during the postpartum period[1] at the time of the post-partum pelvic exam, that would be when the pap smear scraping/procurement would take place.

·         Postpartum visit ( On or between 21 days and 56 days after delivery)

o Pelvic exam and /or weight, BP, breast, and abdomen exam.

o Screen for postpartum depression. Refer for intervention if indicated.

o Screen for domestic violence.

o Discuss sexual activity and contraception with an emphasis on the benefits of long-acting reversible and/or non-reversible contraception.

o Review nutrition and exercise.

o Discuss method of feeding (breast or bottle).

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2.5 Q: If the pap is performed in the middle of the pregnancy is it billable?

2.5 A: If a pap smear is performed during the middle of the pregnancy, it would be billable.  The need for a pap smear would be a medically necessary and separately identifiable diagnosis.  The Pap smear is normally considered a routine part of pre-natal care. If a patient does have an abnormal Pap result during pregnancy, the physician or provider will determine at that time, what (if any)  treatment or procedures can be safely performed based upon the specific diagnosis or reason.  The physician or provider may delay treatment until after delivery.   In this instance, those E&M visits would be billed as a separately identifiable service outside the global package, the procurement of the pap itself is bundled into the E&M and the pap test itself (e.g. 88175) would also be billed with the diagnosis appended.

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2.6 Q:  In the new ICD-10 code set, when do we use the incidental pregnancy code Z33.1?

2.6 A:  In the guidelines from ICD-10cm, the codes from chapter 15 and sequencing priority state:

“ Obstetric cases require codes from chapter 15, codes in the range O00-O9A, Pregnancy, Childbirth, and the Puerperium. Chapter 15 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 15 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1, Pregnant state, incidental, should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.”  2

What this means, is if the patient presents with a separately identifiable diagnosis that is not related to the pregnancy but yet the patient is pregnant, the code Z33.1 should be appended to the claim.  A good example of this is; Patient is 23 weeks and 0/7 days pregnant, … and has been diagnosed with an unspecified sprain of unspecified ligament of ankle, initial encounter.     This would be coded as: S93.401A Initial encounter

Z33.1 pregnant state incidental

Z3A.23 week’s gestation of pregnancy

2.7 Q:  We were told we could not bill for cervical dilation that it is "bundled" into the antepartum.  How can we get this paid???

2.7 A: At this time, the CPT code 59200 states "insertion of cervical dilator"  is considered a separate procedure.  However, according to ACOG, If the service is performed one day (24 hrs) or more prior to a delivery, it can be reported separately.  ACOG also states to use modifier 59 appended to the code 59200 on your claim.  As a coder, you will need to confirm if the cervical dilation service was performed on the SAME DAY as a delivery, it would be considered part of the global package and not separately reported.   

The only other way this service would be billable, is if a non-global physician provided the procedure for code 59200.  In this instance, the non-global (not in the same office, or shares the same tax ID # as the global provider) physician would be able to charge for the cervical dilation.  3

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2.8 Q:  We have had cases where our MD has been called to the labor area (and sometimes even the emergency room) , as the patient came in  thinking she was in labor.  However, labor was ruled out.  Sometimes the patient had just Braxton hicks contractions which we have a good diagnosis to use.  Other times, they thought they were leaking.   We were wondering what type of diagnosis can be used for those times patient "thought" they were leaking but really weren’t. now that ICD-10 has become the new codeset? 

2.8 A:  That is always a tough call, but the patient did arrive to an "emergency" type area.  I have used code O99.89 -- Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium, and I have also used O47.XX False labor section within ICD-10 if the provider documents clearly “false labor”.  Good documentation from the provider is essential in getting a good diagnosis to support the medical necessity for the patient to be seen and billed for the separately identifiable E&M visit within the global care of the pregnancy.  If the provider only documents signs and symptoms, then as a coder you will only code for those that are noted. 

In addition,  when filing  the claim to the insurance carrier, include claim notes to also support your codes and diagnoses (eg  vaginal leaking, pelvic pressure, etc..)  This addition of information added to the claim helps clarify to the erd party payer/carrier exactly "what" the other disease, symptom or condition is.    Don’t forget to add the Z3A.XX weeks of gestation code to provide information to the carrier how far along in the pregnancy the patient is. 

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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/.  

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[1] American College of Obstetricians and Gynecologists (ACOG) Guidelines for Perinatal Care, Sixth Edition October 2007.

2  ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 51 of 115

3  CPT® is registered trademark of the American Medical Association. http://www.ama-assn.org/

Q&A follow-up (part 1) Unbundling the OB Package in ICD-10-Clinical Documentation

Q&A follow-up (part 1)  Unbundling the OB Package in ICD-10-Clinical Documentation

This is a 2-part series of Q&A that was sent in by our listeners of  the Webinar for the HCPro webinar I did entitled " Unbundling the Pregnancy Package in ICD-10"   This can be purchased from HCPro and includes some GREAT information!  (which includes clinical documentation requirements).  We had some great questions, but ran out of time during the Webcast and felt this would be the perfect forum to address those questions, we were unable to during the show. 

As we continue to learn and embrace ICD-10cm, many coders are still feeling uncertain in their ability to code OB delivery and ancillary services as easily as we did the ICD-9.  ICD-10cm has presented some new documentation challenges.  The first 8 Q&A questions are address below.

Q1. During the delivery if the physician documents group B strep positive on the delivery note, do you code O99.824, Z3A.XX, and weeks of gestation?

A1.  Yes, this is proper coding for the GBS notation, however, there also needs to be documentation that this was “complicating” the pregnancy.   A positive GBS culture is considered a pregnancy complication, it is not considered a high-risk pregnancy complication.  Within the documentation the provider should have notated the care associated with GBS, such as the usage of antibiotics prior to or during the delivery itself.  

If the provider notes that the patient is a GBS carrier, or does not consider this to be a complication of the pregnancy, then the code Z22.330 Carrier of Group B streptococcus should be used rather than a “complication” code.   As a coder, if it is unclear whether the provider is considering GBS a complication at the time of delivery, a query may be in order to clarify.
 

Rationale:  16. Documentation of Complications of Care; Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.[1]

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Q2.  In ICD-10 in references the Z3A.XX "weeks of gestation" code for the "weeks" of delivery.  Do we have to put this on every single encounter?

A2.  According to AHIMA, the Z3A.XX weeks of gestation code do not have to be appended at every single encounter.  However this provides an amazing amount of information and data tracking, not only for your office, but also as transparency for the patient, the payer and the physician.  It is incredibly helpful to see that the patient had their 1^st trimester ultrasound at 11 weeks, just by reviewing the claim and/or patient data.

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Q3.  What code are you using when there is a current condition that the mother has, e.g., rheumatoid arthritis?

A3.  Upon delivery if the patient has another current condition that is affecting the delivery itself, it is appropriate to code the sign, symptom, or diagnosis, however, the documentation in a delivery record needs to clearly state whether or not it is a “complication” to the pregnancy, or simply a co-existing medical diagnosis.    In the case above where it is referenced the mother has rheumatoid arthritis, but does not notate a “complication” and the patient has a non-complicated birth, the usage of codes below could be considered.

O80 Encounter for full-term uncomplicated delivery
M06.9 Rheumatoid arthritis, unspecified

Z37.X (birth status)

Z3A.XX (weeks of gestation)

However, if the provider is documenting that the mothers’ rheumatoid arthritis is currently complicating the pregnancy and/or delivery, then the ICD-10 codes could be considered based upon the providers actual documentation/or query

O26.89X Other specified pregnancy related conditions

M06.9 Rheumatoid arthritis, unspecified (or more specificity regarding the RA)

Z37.X (birth status)

Z3A.XX (weeks of gestation)

Rationale:   c. Pre-existing conditions versus conditions due to the pregnancy; 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.[2]

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Q4. What if circumcision is done during delivery? Bill that on a separate claim for infant? Is this a covered procedure?

A43.   In many cases the OB/GYN does do a circumcision on the baby during the delivery hospital stay.  If that provider does perform the circumcision, the patient should receive a charge/billing for that service provided.  The circumcision code will be billed on the infant’s claim with the appropriate CPT code, and under the OB/Gyn provider who performed the procedure.   Many third party insurance carriers do not cover routine circumcision as a covered benefit, so reimbursement may fall to the patient for the entire charge. 

54150 Circumcision, using clamp or other device with regional dorsal penile or ring block

54160 Circumcision, surgical excision other than clamp, device or dorsal slit, neonate (28 days of age or less)

ICD-10 Z41.2 Encounter for routine and ritual male circumcision

Q5. Would you bill with a modifier -51 or -59 for the second baby?

A5.  According to the 2015 ACOG coding manual; If vaginal delivery of twins is performed, report CPT code 59400 and 59409-59 or code 59409 with other appropriate X{EPSU}

sub-modifier per payer policy[3]

The rationale behind this is you have provided only 1 antepartum care for 1 patient (mom)  However, there were 2 fetus’ and you had separately identifiable delivery for 2 fetus’.  Therefore, a global charge of code 59400 is for baby “A”, and a delivery only charge with the appending of mod 59 for baby “B”. 

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Q6.  If patient is admitted to hospital for complication in second trimester how do we indicate this is not delivery so that when the patient delivers we are not denied for it being already paid as part of the global?

A6.  When you are billing for your complication in second/third trimesters and the patient is still pregnant (undelivered) the ICD-10cm diagnosis codes appended will document this.  If and when the patient actually delivers you will append the “Outcome of delivery” codes to the claim, as per the ICD-10 coding guidelines.

Rationale:  Outcome of delivery;  A code from category Z37, Outcome of delivery, should be included on every maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record.  [4]

Outcome of delivery Z37- This category is intended for use as an additional code to identify the outcome of delivery on the mother's record. It is not for use on the newborn record.

Type 1 Excludes stillbirth (P95)

 Z37 Outcome of delivery

 Z37.0 Single live birth

 Z37.1 Single stillbirth

 Z37.2 Twins, both liveborn

 Z37.3 Twins, one liveborn and one stillborn

 Z37.4 Twins, both stillborn

 Z37.5 Other multiple births, all liveborn

 Z37.50 Multiple births, unspecified, all liveborn

 Z37.51 Triplets, all liveborn

 Z37.52 Quadruplets, all liveborn

 Z37.53 Quintuplets, all liveborn

 Z37.54 Sextuplets, all liveborn

 Z37.59 Other multiple births, all liveborn

 Z37.6 Other multiple births, some liveborn

 Z37.60 Multiple births, unspecified, some liveborn

 Z37.61 Triplets, some liveborn

 Z37.62 Quadruplets, some liveborn

 Z37.63 Quintuplets, some liveborn

 Z37.64 Sextuplets, some liveborn

 Z37.69 Other multiple births, some liveborn

 Z37.7 Other multiple births, all stillborn

 Z37.9 Outcome of delivery, unspecified

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Q7.  In ICD-1cm can you bill code 035.3X Maternal care for suspected damage to fetus from drug and code 099.33X Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium at the same encounter?     What about code O99.32X Drug use complicating pregnancy, childbirth, and the puerperium?

A7.  In ICD-10 pay close attention to what the code is actually stating and look at the “key verbiage” within the codeset.

Usage of code O35.3X Maternal Care for suspected damage to fetus from drug, denotes that the provider is concerned with care provided to the mom, due to “suspected” damage to the fetus from drug.   Eg..  the provider may need the mom to have a higher intensity ultrasound of the fetus, or have alternative prescription or social work intervention for a suspected issue with the fetus.

Usage of the code O99.33X is for usage where smoking (tobacco) is specifically noted that the mothers’ usage of tobacco is complicating her pregnancy care and oversight.  Usage of the code O99.32X is for usage where drug usage by the mother (this can be any type of drug, eg prescription necessitated, over the counter, herbal, legal, illegal)  again is complicating the pregnancy care.   

All three of these codes can be coded together, however, when coding O35.3X the provider is required to document the “suspicion” that there may be damage to the fetus from the usage of a particular drug.  (eg.  Pregnancy and patient is currently prescribed drugs for a seizure disorder that may be harmful to a fetus).

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Q8 When twins are born cesarean on different dates (eg past Midnight) How do I bill for this?  

A8.  In this instance, the cesarean procedure date/time will be noted for your claim, and with a twin cesarean, the modifier 22 will be appended for the "mothers" record, and it will look similar to this:

CPT:      59514-22 (twin cesarean delivery)

ICD-10 O82.0 Encounter for cesarean delivery without indication

 Z37.2 Twins, both liveborn

 Z3A.XX Weeks of gestation

However, if Twin A is born at 11:58p.m.  and Twin B is born at 12:02 a.m. (next day)  the babies records will be denoted with the two different dates.   The insurance carrier MAY deny this, so be prepared to submit records with this type of claim.  On each of the baby’s records the Date of Service should correspond to the actual date of delivery.   

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Q9  In regard to fetal non-stress tests (FNST/NST) , if the physician has not done an interpretation but two RNs have reviewed and documented it, can the hospital facility fee be charged?

A9.   The answer to the above is “yes”.  The rationale is the hospital owns the FNST/NST equipment and all equipment/ supplies must be billed for when used in the facility.  The physician bears the responsibility of doing the interpretation of the test, and documenting the medical necessity/indicator for the testing procedure.  The RN’s that reviewed the test, their responsibility lies in getting the service for the usage of the equipment posted in the chargemaster so it will bill out.

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Q10  Would you code Category ll or Category  lll fetal heart tones if mentioned in the delivery chart?  What is documented to show this affects the management of the mother?

A11.  In regard to the actual ICD-10cm coding for a Category II or Category III fetal heart tracing lies in what the provider has actually documented.  The ICD-10cm codes do not correspond do the verbiage “category II or category III”.  ICD-10cm does have codes to represent abnormalities in fetal heart rate and fetal stress.   These codes are found in the code range O76 – O77.9

It is the providers’ duty to provide appropriate documentation of the FNST, and needs to include the medical necessity for the testing (eg diagnosis) .  The clinical documentation from the provider must also support the findings if the testing is noted as a category I, II, or III strip, and how management of the patient is impacted due to the findings within the test.    

According to the guidelines for OBG management and clinical documentation,  A Category I tracing is characterized by a FNST/NST or FHR (Fetal Heart Rate)  tracing, during labor (continuous or intermittent) as:

Category I definition:

·         baseline rate of 110–160 beats/min

·         moderate variability

·         no late or variable decelerations

·         early decelerations being present or absent

·         accelerations being present or absent.

A Category II tracing definition is given to all FHR patterns that cannot be assigned to Category I or Category  III.   A Category II tracing is neither normal nor definitively abnormal.

Category II definition

·         If FHR accelerations or moderate variability are detected, the fetus is unlikely to be currently acidemic.

·         If fetal heart accelerations are absent and variability is absent or minimal, the risk of fetal acidemia increases.

·         Category II tracings should be monitored closely and evaluated carefully.

A Category III tracing shows a clearly abnormal tracing, and is associated with increased risk of fetal acidemia, neonatal encephalopathy, and cerebral palsy.

A Category III tracing is characterized by

·         absent variability plus any one of the following:

• recurrent late decelerations
• recurrent variable decelerations
• bradycardia.

Recurrent late or variable decelerations are defined as those decelerations that occur with 50% or more of contractions. A sinusoidal pattern—characterized by a smooth, sine wave-like, undulating pattern with a cycle frequency of 3–5 waves/min that persists for 20 minutes or longer is also classified as a Category III tracing.

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/

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[1] ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 16 of 115

[2] ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 54 of 115

[3] ACOG 2015 coding manual  page 423

[4] ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Page 54 of 115