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A new Webinar for me – July 2017

I will be doing another AudioEducator Webinar in July. I will be doing a webinar regarding Ultrasound Services in the physician office. We’ll be discussing both Obstetric Ultrasound and Gyncologic Ultrasound. If you’d like to join me – Here’s a $ 20.00 off “coupon code” … and as always… I’ll be Packing in a LOT of info in a short amount of time!!! You always get your $ ‘s worth of info!
Ultrasound Services In The OB/Gyn Office
Presented By: Lori-Lynne A. Webb
Live Webinar | Date: Thu, Jul 20, 2017 | Duration: 60 minutes
Time: 1 pm ET | 12 pm CT | 11 am MT | 10 am PT
https://www.audioeducator.com/…/ultrasound-billing-in-physi…
Become Competent in Billing Ultrasound Services in OB/Gyn Physician Offices
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Lori-Lynne’s Coding Coach Blog

The Medical Necessity Hot Button

Clearing up the confusion surrounding Medical Necessity!

by Lori-Lynne A. Webb, CPC, CCS-P, CCP, COBGC, CHDA  (originally printed through HCPro March 2017)

Understanding and determining medical necessity can be very complex for physicians, clinicians, coders, and billers.A physician or clinical provider of care may have a completely different understanding, interpretation, and definition of medical necessity than the patient or a patient’s family member. A third-party insurance payer may also have another completely different understanding and application of the term.

Defining medical necessity

So what is medical necessity? Coders or billers struggle to understand and sort out as the term, which leads to misinterpretation and misunderstanding of what needs to be communicated in a variety of areas.

CMS provides a specific definition under the Social Security Act:

… no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

In essence, the diagnosis drives medical necessity. Coders need to understand the diagnosis itself, as well as what services or treatment options are available to the provider.

Third-party payers add more confusion

Medical necessity can also be confusing when it comes to who is going to pay for the procedure or services. Many third-party payers have specific coverage rules regarding what they consider medically necessary or have riders and exclusions for specific procedures. Third-party payers may have a specific exclusion for procedures that they consider experimental, unproven for a specific diagnosis, or cosmetic.

One example is a surgeon using a daVinci robotic surgical device to perform a laparoscopic surgery. Upon pre-authorization for the surgery, the insurance payer states it will not pay for the surgery if the daVinci is used. The insurer’s policy includes a rider that deems the daVinci as an experimental surgical device. However, if the physician uses a traditional laparoscopic or open procedure, the third-party payer would reimburse. In this case, the insurance carrier is not stating that the surgery is not medically necessary, just that it will not reimburse for this surgery if the robotic device is used.

Even if a particular procedure or service is considered medically necessary, some payers impose limits on how many times a provider may render a specific service within a specified time frame. For Medicare and Medicaid, these limitations are known as National Coverage Determinations (NCD) and Local Coverage Determination (LCD). Private payers may simply refer to this type of limitation as a policy guideline or policy exclusion or rider.

Within these guidelines, payers may define where or when they will cover a specific service, but may limit coverage to a specific diagnosis. For example, insurance policies may have a wellness or preventive care benefit, but may only cover one such visit per year. Some payers may only reimburse for a single Prostate-Specific Antigen (PSA) test per year. The payer may require a documented screening diagnosis in coordination with the test.

If the patient underwent a PSA test January 1, 2012, for screening, his insurance may not pay for another test until 365 days (or one calendar year) have elapsed. However, if the patient undergoes a PSA blood test for screening and the test results are abnormal, the clinician may decide another PSA test is needed. The coder must submit that claim as a PSA blood test with the appropriate diagnosis for a sign, symptom, or abnormality, not as a screening.


Documenting medical necessity
Medical necessity continues to be open for interpretation by all parties involved. Many third-party payers have created lists of criteria they use to interpret medical necessity. These lists do not necessarily reflect all options, but payers include this reference in their policy guidelines.

Most providers have not developed a comprehensive listing of medically necessary qualifiers, so coders and clinicians must focus on good documentation and coding accuracy to communicate the medical necessity of services accurately to payers. If third-party payers deny reimbursement for medical services, physicians, clinicians, and coders need to rely on the formal appeal process.

Medical necessity documentation from a physician or provider should include the following:

§  Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is our diagnosis driver, and multiple diagnoses may be involved.

§  Probability of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated. This is the medical risk vs. gain.

§  Need and/or availability of diagnostic studies and/or therapeutic intervention(s) to evaluate and investigate the patient’s presenting problem or current acute or chronic medical condition. In other words, does the facility, office, or hospital have what the provider or clinician needs to render care?

These bullet points reflect the basics of evaluation and management (E/M) guidelines that are currently in place from CPT®: the history, exam, and medical decision making processes. Coders will have an easier time evaluating medical necessity from this aspect. Of course, a good understanding of this integration of medical necessity within the E/M guidelines makes communicating this same principle to the providers much easier. Coders should encourage providers to continually enhance their documentation to improve overall coordination between the medical record, coding accuracy, and third-party payer reimbursement.

The third-party payers employ a wide spectrum of policies defining medical necessity is and should encompass. Physicians, clinical providers, and coders should review what these payers have established within their guidelines. Someone within the physician office, hospital, or medical facility should thoroughly scrutinize these guidelines before establishing a contractual relationship with a particular third party payer. This up-front communication will help avoid claim denials in the future.

Here are some examples of what some third party payers are currently including in their medically necessary verbiage:

§  Treatment is consistent with the symptoms or diagnosis of the illness, injury, or symptoms under review by the provider of care.

§  Treatment is necessary and consistent with generally accepted professional medical standards (i.e., not experimental or investigational).

§  Treatment is not furnished primarily for the convenience of the patient, the attending physician, or another physician or supplier.

§  Treatment is furnished at the most appropriate level that can be provided safely and effectively to the patient, and is neither more or less than what the patient is requiring at that specific point in time.

§  The disbursement of medical care and/or treatment must not be related to the patient’s or the third party payer’s monetary status or benefit.

Documentation of all medical care should accurately reflect the need for and outcome of the treatment.
Treatment or medical services deemed to be medically necessary by the provider of those services,(e.g., physician, therapist, clinician, etc.) does not imply or infer that the service(s) provided will be covered by or deemed a medically necessary service payable by a third-party insurance payer.

Medical Necessity Q&A

Q:  Could you give me some guidance on how I can instruct my MD’s on avoiding vague and/or subjective clinical documentation?
A:.  Ask your providers to adequately describe his/her skilled care providedand give a clear picture of the treatment and/or “next steps” to be taken.
Do not use vague or subjective descriptions like “tolerated treatment well,” “improving,” “caregiver instructed on med management,” or “continue with plan of care.”   “patient is here for follow up”
examples of more complete and compliant statements:
1.     Patient tolerated ROM exercises with a pain level of 6/10.
2.     Patient was able to verbalize understanding and importance of checking their blood sugars prior to administering insulin.
3.     Plan for next visit: to continue education on importance of daily inspection of feet for diabetic patient, provide wound care, etc.
Q  I work in dermatology and need to know what documentation is required for excisions?  We are struggling with getting paid  
A:  The provider should include the actual “size” of the lesion/mass they are going to excise.  Then they should document the area of the excision which needs to include the lesion + any margins.  (Height, Width, Depth) and if circular/elliptical etc… and denote the “why” it was performed that way.    If you have to appeal, the problem with using strictly the sizes from a pathology report, is that tissue “shrinks” once it is excised, and the would “enlarges” once the tissue is excised. 
Q.  What is the BEST way to document our time spent… the CPT codes state a vague “time” amount but the doctors struggle with this..  
A.  Notation of Time in/Time out is always very helpful…  it is also helpful if the provider “explains”  the time.  Eg –  spent 20 minutes of our 30 minute visit discussing how to properly use their new asthma inhaler.  Or  I was requested by Dr. Doe for “standby” for a possible cesarean section during vaginal delivery.  I entered the delivery room at 0800 and departed at 0915 status post a successful vaginal delivery.

Coders must understand the complex relationships between the physician, the patient, the medical record documentation, the coder, the biller, the insurance payer, and the communication between all of these entities to successfully guide the interpretation of medical necessity.

Lori-Lynne’s Coding Coach Blog

HOT OFF THE PRESS!! CMS Instruction manual for NCCI Edits

Good Morning!  CMS has now published a current instruction manual for usage of the NCCI “bundling” edits for billing providers.   Not only is the manual helpful, but you can also download the latest NCCI bundling edits for your codes FREE OF CHARGE!!!    This is a great help to all practices.

Lori-Lynne’s Coding Coach Blog

Coding for Cervical Cancer Screening – Pap test results, definitions and ICD-10

This was originally written back in April of 2016….  
4/23/2016
Cervical Cancer Screening – Pap test results, definitions and ICD-10
A Cervical cancer screening test, also known as a Pap (Papanicolaou test) is used to find abnormal changes in the cells of the cervix.  If abnormal cells are found, those cells can potentially mutate into cancer cells within the cervix.   Cervical cancer screening includes the Pap test and, some providers also perform an HPV (Human Papilloma Virus) test. 
When the provider performs a screening or diagnostic Pap test, both tests use cells taken directly from the cervix. The cells that are removed from the cervix, put into a special liquid and sent to the laboratory for testing.  If only the Pap test is performed, the cells are reviewed and examined to see if any “abnormal” cells are present with “normal cells”.  When the HPV testing is performed, the cells are then reviewed to see if the HPV virus is present within that sample.  Most pathology labs will sample for 13 or 14 of the most common high-risk HPV types. 
According to ACOG (The American College of Obstetrics and Gynecology), the main cause of cervical cancer is infection with HPV. Unfortunately, there are many types of HPV, and some of the HPV infections are considered “high-risk” types.  It has been determined that with the most common cases of cervical cancer; most cervical cancers are narrowed down to two high-risk types of HPV—type 16 and type 18.  It is the abnormal cell types that can be found with these screening tests.  Abnormal changes can range from mild to a full blown case of cervical cancer.
Pap tests are most commonly procured at the time of the well woman exam, and are performed primarily as a screening tool for cervical cancer.  However, with the Pap test, sometimes the cells from the vagina are taken if the woman does not have a cervix. 
Pathology Acronyms and Definitions
As coders, we must know and understand all definitions that affect the diagnosis codes that we append to the procedure codes.  It is extremely important that we do not append an incorrect diagnosis to a patients’ medical record or billing.   The acronyms for cervical cancer screening tests are numerous.  Many of these terms have similar sounding verbiage, yet the definitions do not mean the same things. 
When reviewing the pathology documentation, the term ASCUS, is commonly seen.  This acronym means “Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASCUS)”.   Squamous intraepithelial lesion (SIL) is an acronym used to describe Pap test results. “Squamous” refers to the type of cells that make up the tissue that covers the cervix. SIL is not a diagnosis of pre-cancer or cancer.  In ICD-10 the term SIL is not noted, however, ICD10cm does refer to many of the other acronyms associated with pathology cells and cell types that are found with the Pap test.
The Pap test is most commonly performed as a screening test for changes to the cells within the cervix, but can also be used as a diagnostic tool too.   The changes in cell types found on the cervix can be a possible pre-cursor to a cervical cancer, or can be completely benign. If the changes in some of the cells cannot be exactly diagnosed, or noted by how severe the changes are in cervical cells, this would be documented on the pathology report as an ASCUS pap finding. 
To correctly code for an ASCUS pap we would look at the code of R87.610.  (R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US).  The R87 code set is part of the codes that are symptoms, signs and abnormal clinical and laboratory findings.  In addition to the ASCUS documentation on a pap result, the terms LGSIL and HGSIL may also be found.   LGSIL acronym stands for “Low grade squamous intraepithelial lesion on cytologic smear of cervix” . The term HGSIL is for the notation of “High grade squamous intraepithelial lesion on cytologic smear of cervix”.
Abnormal cytological findings in specimens from female genital organs
*      R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)
*      R87.612 Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)
*      R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)
Atypical squamous cells, cannot exclude HGSIL the possibility that there have been changes in the cervical cells found that raise concern for the presence of HGSIL.
Atypical glandular cells (AGC)—Glandular cells are another type of cell that makes up the thin layer of tissue that covers the inner canal of the cervix. Glandular cells also are present inside the uterus. An AGC result means that changes have been found in glandular cells that raise concern for the presence of pre-cancer or cancer.
If the term cervical dysplasia is documented, this term indicates that abnormal cells were found on the surface of the cervix.  A cervical dysplasia is classified as mild, moderate or severe, depending on the appearance of the abnormal cells.  Cervical dysplasia can disappear on its own or, it can develop into a more malignant form such as a neoplasm/cancer. Cervical dysplasia is also known as a Cervical Intraepithelial Neoplasia, or denoted as CIN. 
In ICD-10, if the term “mild cervical dysplasia” is documented and/or the term CIN I the corresponding code in ICD-10cm is to be coded to N87.0.    If the term “moderate cervical dysplasia”  and/or CIN II is documented, those terms correlate to be coded as N87.1.    However, if the term “severe cervical dysplasia”  and/or CIN III is documented , ICD-10cm guides us to the code set of D06.# and is denoted in ICD-10cm as a carcinoma in situ of the cervix uteri.   If the provider did not specify if the dysplasia is mild, moderate or severe, then the unspecified code of N87.9 should be chosen.   If the documentation is noted to be severe, then the code chosen in the D06’s needs to be specified as to endocervix, exocervix, other parts of cervix, or unspecified.   As you can see from the codes below a severe dysplasia is considered to be a carcinoma, in situ; meaning it is contained within the cervix . 
D06 Carcinoma in situ of cervix uteri
http://www.icd10data.com/images/2.gifD06.0 is a specific ICD-10-CM diagnosis code D06.0 Carcinoma in situ of endocervix
http://www.icd10data.com/images/2.gifD06.1 is a specific ICD-10-CM diagnosis code D06.1 Carcinoma in situ of exocervix
http://www.icd10data.com/images/2.gifD06.7 is a specific ICD-10-CM diagnosis code D06.7 Carcinoma in situ of other parts of cervix
http://www.icd10data.com/images/3.gifD06.9 is a specific ICD-10-CM diagnosis code D06.9 Carcinoma in situ of cervix, unspecified
 N87 Dysplasia of cervix uteri
http://www.icd10data.com/images/2.gifN87.0 is a specific ICD-10-CM diagnosis code N87.0 Mild cervical dysplasia
http://www.icd10data.com/images/2.gifN87.1 is a specific ICD-10-CM diagnosis code N87.1 Moderate cervical dysplasia
http://www.icd10data.com/images/3.gifN87.9 is a specific ICD-10-CM diagnosis code N87.9 Dysplasia of cervix uteri, unspecified
Glandular cells are another type of cell that make up the thin layer of tissue that covers the inner canal of the cervix.  Atypical glandular cells (AGC) can also be denoted on the pathology report, and those cells may be present in the specimen that was procured at the time of the Pap test.  These glandular cells also are present inside the uterus.  If a pap test denotes the patient has an AGC result, this represents changes have been found in glandular cells, which raises the concern for the presence of pre-cancer or cancer not only on the cervix, but a possibility of cancer cells that may be present in the uterus.
If the patient does have an abnormal cervical cancer screening (Pap) test result, the patient may require further testing. The first line of treatment is most often a repeat Pap test or a repeat Pap test and include testing for high-risk types of HPV.  Additional testing or procedures are recommended as a follow-up to some abnormal test results.  In addition to the Pap test, the provider may want to perform a colposcopy, biopsy, and endocervical sampling.  A colposcopy procedure is an examination of the cervix with a magnifying device that includes the tools to take a more in-depth sample of the cervix or targeted area on the cervix.
If an area of abnormal cells is seen, the physician may decide to perform a cervical or vaginal biopsy.   An endocervical and possibly an endometrial sample biopsy also may be done if the initial pap did show AGC.  As with any screening or diagnostic testing, follow up with the provider is crucial. 
When coding any of these tests, be sure that all results are clearly documented by the provider.   When coding for the initial procurement of the pap test, the codes below would be used  to bill for the procedure/procurement of the pap specimen, and for connecting the diagnosis driver to the screening process through the designation of an E&M code for the Wellness/well-woman exam. 

CPT codes 99384 – 99387 (new patient)
CPT codes 99394 – 99397 (established patient)
ICD-10: Z12.4 Encounter for screening for malignant neoplasm of cervix
ICD-10: Z12.72 Encounter for screening for malignant neoplasm of vagina
ICD-10: Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
HCPCS: Q0091 Screening Pap smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
            Note: The HCPCS Code Q0091 is a HCPCS code developed by Medicare for services provided to Medicare patients.  Medicare allows payment of code Q0091 for the collection of the pap specimen itself, and should only be reported if performed as a screening process.  The Q0091 is not to be reported if the pap testing is performed for a diagnostic or medically indicated reason.
In the table below, the most common CPT and HCPCS codes reported out by the laboratory for testing
Code Number
Description
CPT-4
87620
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, direct probe technique (Deleted 12-31-2014)
87621
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique (Deleted 12-31-2014)
87622
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus (HPV), human, quantification (Deleted 12-31-2014)
87623
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) (New 01-01-2015)
87624
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (New 01-01-2015)
87625
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed (New 01-01-2015)
88142
Cytopathology, cervical or vaginal, (any reporting system) collected in preservative fluid, automated thin layer preparation, manual screening under physician supervision (ThinPrep)
88143
Cytopathology, cervical or vaginal, (any reporting system) collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening under physician supervision
88147
Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision
88148
Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision
88152
Cytopathology, slides, cervical or vaginal, with manual screening and computer-assisted rescreening under physician supervision
88154
Cytopathology, slides, cervical or vaginal, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88166
Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening and computer-assisted rescreening under physician supervision
88167
Cytopathology, slides, cervical or vaginal, (Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88174
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision
88175
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision
HCPCS (normally used for Medicare patients)
G0123
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision
G0124
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician
G0141
Screening cytopathology, smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
G0143
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision
G0144
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision
G0145
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision
G0147
Screen cytopathology smears, cervical or vaginal, performed by automated system under physician supervision
G0148
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening
P3000
Screening Papanicolaou smear, cervical, or vaginal, up to three smears, by technician under physician supervision
P3001
Screening Papanicolaou smear, cervical, or vaginal, up to three smears, requiring interpretation by physician
Wrapping it up
As a coder, remember to code what you know, and do not assume a correlation, or that similar “sounding” terms really mean the same thing.   If in doubt, or the documentation does not appear to be clear or is confusing, query the provider.  Good patient care requires the provider to accurately reflect the patient care via their documentation in the medical record.  Our job, as a coder, is to correlate the coding and billing to reflect the medical that was documented and provided by the physician.  If you are unsure about the coding guidelines utilize your resources such as CPT, ICD-10cm, ICD-10pcs and HCPCS. 

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/.   

Lori-Lynne’s Coding Coach Blog

Coding for Initial Encounter; Subsequent Encounter; Sequela: ICD-10 documentation Challenges

Coding for Initial Encounter; Subsequent Encounter; Sequela:  ICD-10 documentation Challenges 
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
Originally Published: May 15, 2016
A bit of Background
ICD-10cm has been fully implemented, however the struggle is still very “real” to both inpatient and outpatient coders that spend the majority of the work day performing diagnosis coding.  The issue at hand is trying to gain perspective regarding whether the encounter should be considered “initial”  “subsequent” or “sequela” when coding from ICD10cm chapters 19 and 20.   These chapters contain the codes for injuries, poisonings, and other external causes. 
Unfortunately, physician and mid-level care providers also struggle with the clinical  documentation required for accurate coding within this code set.  One area in particular, is documentation to support, or to define the “initial”, “subsequent” or “sequela” for care provided.    Upon review of medical care provided, physician providers are very good at documenting when the issue is “initial”  or “subsequent”, however the “sequela” or late effect documentation remains an issue of concern.  
In ICD-10cm, the diagnosis is meant to describe the complete reason(s) why a patient is seeking care during a specific encounter with a provider or facility.  This may be a simplistic observation, however, with the onset of the new ICD-10cm codes and its implementation on October 1, 2015; the usage of the term(s) initial, subsequent and sequela have not only taken on a specific meaning in relation to the code set but requires coders  to append the seventh character for injuries, poisoning and other consequences regarding the diagnosis and patient care for injuries, burns and fracture care.  
As we have learned, the seventh character indicates coders to use the letters: A – Initial encounter; D – Subsequent encounter and S – Sequela.    A, D, and S usually represent the diagnosis from the patient’s perspective, however, in the ICD-10cm guidelines note that if the visit/encounter  is a patient’s initial encounter for active treatment of the injury, it’s to be considered and coded as an initial encounter. The patient may be seen by a new or different provider over the course of treatment for an injury.   Again, the assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.
Understanding Critical Verbiage
As a coder, it is imperative that we understand the differences and are able to discern if the care being provided is considered “active treatment” care, or if the care provided is considered a subsequent treatment care phase.  The usage of the 7th character “A” requires definitive clinical documentation and clarity of the care being performed.  In addition, clarity regarding the term “active care” needs to be well documented within the medical record and is paramount to successfully coding “active treatment” correctly. 
Examples of active treatment are:
·         surgical treatment
·         Emergency department encounter
·         Evaluation and continuing management treatment by the same or a different physician
The 7th character “D” subsequent encounter,  is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.
Examples of subsequent care are:
·         Cast change or removal
·         An x-ray to check healing status of fracture
·         Removal of external or internal fixation device
·         Medication adjustment,
·         Other aftercare and/or  follow up visits following treatment of the injury or condition
The 7th Character of “S” is to be used to denote a sequela , late effect, complication or condition that arises due to the direct result of an injury or complication of care.  Sequela is defined by the ICD-10 guidelines as “…the residual effect (condition produced) after the acute phase of an illness or injury has terminated.” There is no time limit on when a sequela code can be used. The residual complication or “sequela” may be apparent soon after subsequent care has been completed,  or it may occur months or even years later.
Examples of Sequela include
·         scar formation resulting from a burn
·         deviated septum due to a nasal fracture
·         chronic pain from previous back injury
When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code.  The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.
Procedure Documentation Scenario:
Scenario for “A” Initial Encounter

An adult patient is evaluated in the emergency department (ED ) for a traumatic rupture of the right ear drum. The ED provider informs the patient that the ENT physician is unavailable at this time, and provides the patient with painkillers.  The patient is then instructed by the ED to present to the ENT office directly upon discharge from the Emergency department care.  Coding for the care in the ED would be reported with ICD10cm code S09.21A  Traumatic rupture of right ear drum.
The patient then presents to the ENT office, and the provider  rechecks the patient and applies a paper patch to the eardrum in the ENT office.  At this time, the patient is receiving  active treatment for this injury.
In summation; this is the first encounter at which the patient receives definitive care (the ED was able to apply comfort care only and referred on to the ENT). Per ICD-10 guidelines, you would again report S09.21A for an initial encounter at the ENT office. 
Scenario for “D”  Subsequent Encounter
An adult patient is evaluated in the emergency department (ED ) for a traumatic rupture of the right ear drum. The ED provider informs the patient that the ENT physician is unavailable at this time.  The ED provider applies a paper patch to the eardrum while the patient is still in the ED per request of the ENT physician, and provides the patient with painkillers upon discharge from the ED.  .  The patient is then instructed by the ED to present to the ENT office directly upon discharge from the Emergency department care.  Coding for the care in the ED would be reported with ICD10cm code S09.21A  Traumatic rupture of right ear drum, initial encounter. 
The patient was instructed upon discharge from the ED to follow up with the ENT in one week to ensure healing of the eardrum.  One week later the ENT provider rechecks the ear-drum injury in the office.  As per ICD-10cm guidelines, this care would be considered  a subsequent encounter, and would be reported as S09.21D traumatic rupture of right ear drum subsequent encounter.  
 The rationale for the subsequent encounter code,  is the ENT provider cared for the same condition, but was not performing “active care”  but “follow up” care for the injury.  
Scenario for “S”  Sequela
Scenario 1:
A patient is admitted to a longterm acute care facility for chronic respiratory failure and ventilator dependency after an acute admission for treatment of an accidental drug overdose.
 – Assign code J96.10, Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, as the principal diagnosis

 – Assign secondary codes – T50.901S, Poisoning by unspecified drugs, medicaments and biological substances, accidental (unintentional), sequela

– Z99.11, Dependence on respiratory [ventilator] status
Scenario 2:
A patient presents for release of skin contracture due to third degree burns of the right hand that occurred due to a house fire five years ago.
Assign code(s)
         L90.5, Scar conditions and fibrosis of skin, as the principal diagnosis.
         T23.301S, Burn of third degree of right hand, unspecified site, sequela
         X00.0XXS, Exposure to flames in uncontrolled fire in building or structure, sequela
Scenario3:
A 29 year old female patient has presented to the Internal Medicine specialty clinic to establish care.  She is a complete paraplegic due to a tramatic L3 vertebral fracture 8 years ago due to a motor vehicle accident.  In her intake, she does not have any other current problems.  
Assign code(s)
         G82.21 paraplegia complete
         S32.029S Fracture traumatic vertebra, lumbar, second.
Clinical documentation:   a look to the future….
Good clinical documentation for accurate coding of the 7th placeholder in ICD-10cm is necessary not only for the claims process, but to ensure transparency and clarity for the medical record.  Fracture and burn documentation have additional requirements for coders to clearly code care that is rendered.  The Clinical documentation needs to include:
**Documentation for a current encounter:
– Diagnoses current and relevant
         Clearly denotes;  “active”  treatment; “subsequent” treatment or “sequela” .
**Clinical Documentation for Fractures need to include:
• Cause:
– Traumatic
– Stress
– Pathologic
• Location:
– Which bone?
– Which part of the bone?
– Laterality (right, left, or bilateral)
• Type:
– Non-displaced
– Displaced
– Open (Gustilo classification where applicable)
– Closed (Greenstick, spiral, etc.)
– Salter-Harris (specify type)
• Encounter:
– Initial
– Subsequent
° For routine healing
° For delayed healing
° For non-union
° For malunion
– Sequela (such as bone shortening)
• Include the external cause of the fracture, such as fall while skiing, motor
vehicle accident, tackle in sports, etc.
• Document any associated diagnoses/conditions
**Clinical documentation for burns need to include:
• Type:
– Corrosion
– Thermal
• Site:
– Specify body part
– Include laterality
• Degree:
– First
– Second
– Third
• Document total body surface area (TBSA) burned (percentage)

• Specify the percentage of third degree burns

• Include the external cause of the burn, such as house fire, stove, acid, etc.

• Document any associated diagnoses/conditions
Final thoughts – wrap it up neatly
As a coder, when coding these difficult treatment scenarios, always read the ICD-10cm guidelines thoroughly and pay close attention to any includes or excludes statements, present on admission, primary, secondary and all pertinent diagnoses. 
If the medical record documentation is not clear to you, or you are uncertain regarding “initial, subsequent, or sequela” query the provider or ask for clarification regarding the scope and definition of care that has been provided to the patient.

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

Lori-Lynne’s Coding Coach Blog

Sterilization forms and coding: documentation tips post ICD-10 implementation

Sterilization forms and coding:  documentation tips post ICD-10 implementation
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
Originally published: March 25, 2016
Coding and reimbursement for sterilization has more to it than simply applying the CPT code, diagnosis code, submitting the claim and “voila”  having the reimbursement dollars  magically appear in the revenue stream. 
The Federal Government has regulations in place that need to be followed for those providers that perform sterilizations and accept reimbursement from federally funded payers.    These mandates are found within U.S. Code: Title 42 – The public health and welfare  and are contained in the laws within Title 42.  The sterilization consent form requirements can be officially found  within; Title 42; Chapter I, Subchapter D, Part 50, Subpart B,  Section 50.205.  This is commonly referred to as  “42 CFR 50.205 – Consent form requirements”
If you are a provider who performs sterilization procedures on a frequent basis, you are probably well versed in the process of getting this form filled out correctly and getting reimbursement.  Many providers who only occasionally provide sterilization services are unaware of this mandated form, and either get the form filled out incorrectly, or don’t get the form filled out at all.  This creates issues for the entire practice, and impacts the revenue you rightly deserve for providing this care.   The requirement of this form is non-discriminatory, in the fact that it has to be filled out and utilized for those who perform sterilization procedures on men as well as those sterilization procedure performed on women.
50.205 Consent form requirements
“42 CFR 50.205” contains these parameters to be fulfilled
(a)   Required consent form. The consent form appended to this subpart or another consent form approved by the Secretary must be used.   link to federal form HHS-687
(b) Required signatures. The consent form must be signed and dated by:
(1) The individual to be sterilized; and
(2) The interpreter, if one is provided; and
(3) The person who obtains the consent; and
(4) The physician who will perform the sterilization procedure.
(c) Required certifications.

(1) The person obtaining the consent must certify by signing the consent form that:

(i) Before the individual to be sterilized signed the consent form, he or she advised the individual to be sterilized that no Federal benefits may be withdrawn because of the decision not to be sterilized,

(ii) He or she explained orally the requirements for informed consent as set forth on the consent form, and

(iii) To the best of his or her knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized.

(2) The physician performing the sterilization must certify by signing the consent form, that:

(i) Shortly before the performance of the sterilization, he or she advised the individual to be sterilized that no Federal benefits may be withdrawn because of the decision not to be sterilized,

(ii) He or she explained orally the requirements for informed consent as set forth on the consent form, and

(iii) To the best of his or her knowledge and belief, the individual to be sterilized appeared mentally competent and knowingly and voluntarily consented to be sterilized. Except in the case of premature delivery or emergency abdominal surgery, the physician must further certify that at least 30 days have passed between the date of the individual’s signature on the consent form and the date upon which the sterilization was performed. If premature delivery occurs or emergency abdominal surgery is required within the 30-day period, the physician must certify that the sterilization was performed less than 30 days but not less than 72 hours after the date of the individual’s signature on the consent form because of premature delivery or emergency abdominal surgery, as applicable. In the case of premature delivery, the physician must also state the expected date of delivery. In the case of emergency abdominal surgery, the physician must describe the emergency.

(3) If an interpreter is provided, the interpreter must certify that he or she translated the
information and advice presented orally, read the consent form and explained its contents and to the best of the interpreter’s knowledge and belief, the individual to be sterilized understood what the interpreter told him or her.
Critical verbiage and procedures
As you can see from the above, there are a lot of “rules” to be followed.  However, the government has given us a standardized form to use and be implemented by the providers.  They have even given us an electronic type version that can be downloaded and filled in, or even filled in on-line.  This form can be found at  http://www.hhs.gov/opa/pdfs/consent-for-sterilization-english-updated.pdf.   This government form is currently valid for use though 12/31/2018.  
The critical verbiage that must be followed closely is the mandate that “at least 30 days have passed between the date of the individual’s signature, and the date for when the sterilization is performed”.   If this is not followed closely, the physician and the facility/hospital will not be paid. 
This form is used across the United States, however, some State funded Medicaid programs may use their own form, but it has to contain the minimum information that has been outline in 42 CFR 50.205.  
When implementing the procedure to get this form completed correctly, all staff, and especially the physician/provider,  should be aware of its content and ensure that it is filled out correctly.   This seems like more government buracracy  however, if you are a Medicare/Medicaid provider this is part of the process we must perform to ensure the patient fully understands the implications of sterilization, and that as a patient they consent to the procedure.
ICD-10 diagnosing –  ICD-10 procedure – CPT procedure
In the post ICD-10cm and ICD-10pcs world things have changed for the coding and reimbursement for sterilization codes. 
In ICD-9cm we used code V25.2; Sterilization
In ICD-10cm we now use code Z30.2; Encounter for Sterilization
The codes are very similar, but in ICD-10cm they expanded the description to state that the usage of the code was for the encounter  for sterilization –  not just stating the word “sterilization” .    So for the diagnosing of sterilization procedures it remains straightforward for the diagnosis of the sterilization procedure.
However, that is not the same for ICD10pcs.  In ICD10pcs, the procedure of “vasectomy” is found in the index, and you’re referred to the code tables that provide the codeset for   a procedure performed on the male reproductive organ system.    The same can be said for the term  “tubal ligation”   as when you go to look it up the ICD-10pcs system as a tubal ligation, it refers you to the term “occlusion”  where as you view the index, you find  “Occlusion; Fallopian Tube; Left, Right, Bilateral”  and refers you to the table sections that are appropriate.   (see attached pages)  
CPT procedures have many different codes that can be used for “sterilization procedures”  so careful review of the operative reports to determine the correct code is a vital piece to ensuring your smooth reimbursement of sterilization procedures.
If you look in the CPT manual index, you will find the term for the “vasectomy”procedure, and CPT refers you to the numeric code of 55250.  In the CPT codeset the code 55250 is found in the surgery/male genital system section under Vas Deferens; Excision; then the code 55250 is the only code that appears in this subset.  If your provider does the traditional vasectomy procedure this is the correct code to use.  However, there have been newer and less invasive techniques for “vasectomy”  so code 55250 may not be the correct choice.   It is this new technology that requires coders to carefully review the operative note(s) to ensure the correct CPT code goes with the correct diagnosis. 
The same can be said for coding of sterilization for female patients.  In the CPT manual sterilization codes for female patients can range from a very simple to extremely complex invasive procedures.  CPT includes sterilization procedures that range from simple “incision” type procedure, and include codes for sterilization procedures that utilize  laparoscopic technique, hysteroscopic technique,  percutaneous incision, to abdominally open surgical procedures.  CPT even includes codes that factor in a sterilization performed at the time of delivery (with a cesarean section)  or even performed shortly after a vaginal delivery.
Diagnosis beyond “encounter for sterilization”
In cases where a sterilization is being performed, not all sterilization procedures are performed strictly for birth control.  Providers, clinical personnel, and coders all need to ensure that the coding and documentation for a sterilization procedure is clearly reflective of why the procedure is being performed.  Sterilization procedures may be required for a medically necessary or medically indicated diagnosis. 
If a sterilization procedure is needed by the patient, this does not absolve us from not getting the proper paperwork filled out. (eg the federal sterilization form, appropriate consents, pre-authorizations, and referrals)   In the case of a female patient requiring an emergent type of sterilization procedure, the 42 CFR 50.205 federal form allows for this circumstance in which the form still needs to be filled out, but the caveat of “emergency abdominal surgery” is noted on the form, and in the patients’ medical record.
When filling out the claim form for sterilization procedures that are not for contraceptive reasons, the medically necessary diagnosis would be appended first;  then any additional medically indicated symptoms or diagnoses, with the final code of  Z30.2; Encounter for Sterilization.  When sequenced, this paints the picture of a medically indicated procedure, and denotes that the patient is also rendered sterile.
Prior to sending your claim, take the time to review the sterilization form and review it has been filled out correctly,  all signatures and dates are correct and within the mandated guidelines.  If the form is incomplete, or incorrect take the time to make all necessary corrections, and get all necessary signatures. 
As you submit your claim, if it is an electronic claim, you may be required to submit a copy of the signed sterilization form, the operative report and also supporting medical records with your claim.  If you are still submitting your claim as hard copy, you will need to include these documents as hard copy.  
Final thoughts – wrap it up neatly
As a coder, you now have the unique opportunity to connect with your providers, clinical back office personnel, and your first line patient representatives to ensure that all the appropriate forms are filled out.  You can provide the education and the importance of the sterilization form,  and the importance of clear documentation to determine the reasons for the sterilization procedure. (eg, if done for “contraceptive or birth control” or “medically necessary/medically therapeutic” ).
If the sterilization procedure is denied for payment by the insurance carrier, review the denial code carefully, and if needed, contact the carrier to fully determine the cause of the denial.   If warranted, appeal your denial. 

For “male sterilization “ procedures performed in ICD-10 PCS

 … for female sterilization “tubal ligation” procedures in ICD-10 pcs



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/.   

Lori-Lynne’s Coding Coach Blog

Coding and Billing for Infertility services and procedures


Coding and Billing for Infertility services and procedures
Originally Published: July 16, 2016
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC


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


According to the AIUM (American Institute of Ultrasound in Medicine©) they define female infertility as:
“Female infertility shall mean the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35. For purposes of meeting the criteria for infertility in this section, if a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1 year or 6 month period, as applicable.”


According to the Mayo Clinic (© 1998-2016 Mayo Foundation for Medical Education and Research) Male infertility is defined as:
“A male’s inability to cause pregnancy in a fertile female in light of unprotected sexual intercourse for a year or longer.”   
Treatment Options
There are many varied treatments for fertility issues.  However, the root cause of the infertility will drive what options are utilized.  In women, infertility may be caused by ovary dysfunction, blocked or damaged fallopian tubes, uterine disease processes such as fibroid tumors or endometriosis, cervix  stenosis, endocrine hormone dysfunction and in some cases, stress and/or medication side effects.  It has been noted in some studies that up to 15% of infertility cases, the actual cause may remain unexplained. In men, infertility may be caused by obstruction of the testes, epididymis, vas deferens, ejaculatory duct, distal seminal ducts, varicocele, hypogonadism, cryptorchidism, reproductive gland infections, ejaculatory disorders, or hormonal deficiencies with testosterone or endocrine malfunction.  
Female infertility can be treated in several ways, including:
Laparoscopy: This is usage of a surgical technique using a laparoscope to remove any scar tissue, endometriosis, ovarian cysts or open/re-open blocked fallopian tubes.
Hysteroscopy: Is usage of a hysteroscope, placed into the uterus which can be used to remove polyps, fibroid tumors, endometriosis, scar tissue, open/re-open blocked fallopian tubes.
Medical therapy: (Drug therapy for ovulation problems) Medications prescribed such as clompiphene citrate (Clomid, Serophene), letrozole, or gonadotropins can help induce ovulation,  Other drugs such as Metformin (glucophage) may be prescribed for women who have insulin resistance, or PCOS (Polycystic Ovarian Syndrom)
Intrauterine sperm insemination: ISI refers to an office based  procedure where semen is collected, rinsed with a special solution, and then placed into the uterus at the time of ovulation.  
In vitro fertilization:  IVF refers to a procedure in which eggs are fertilized in a culture dish and placed into the uterus.)
Intracytoplasmic Sperm Introduction: ICSI is a procedure where sperm is injected directly into the egg in a culture dish and then placed into the woman’s uterus
GIFT (Gamete intrafallopian tube transfer)/ ZIFT (zygote intrafallopian transfer): These procedures are similar to IVF.  Both procedures involve retrieving an egg combining with sperm then transplanting back into the uterus. (In ZIFT, the fertilized eggs — at this stage called zygotes — are placed in the fallopian tubes within 24 hours. In GIFT, the sperm and eggs are mixed together before being inserted.)
Egg donation: The egg donation procedure involves the removal of eggs from the ovary of a donor, then placed mixed with the sperm from the recipient’s partner and transplanted into the uterus via the IVF procedure.


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


ICD-10cm code set guidelines


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


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


ICD-10cm code set for female infertility:
N97 Female infertility
Includes: inability to achieve a pregnancy, sterility, female NOS


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


Excludes2:  incompetence of cervix uteri (N88.3)
  • N97.0
    • Female infertility associated with anovulation
  • N97.1
    • Female infertility of tubal origin
    • Female infertility associated with congenital anomaly of tube
    • Female infertility due to tubal block
    • Female infertility due to tubal occlusion
    • Female infertility due to tubal stenosis
  • N97.2
    • Female infertility of uterine origin
    • Female infertility associated with congenital anomaly of uterus
    • Female infertility due to non-implantation of ovum
  • N97.8
    • Female infertility of other origin
  • N97.9
    • Female infertility, unspecified


ICD-10cm code set for male infertility is found within the chapter 14 “N” codes too.  Male infertility is represented with the codes of N46 and excludes the code Z98.52 which represents a vasectomy status.
  • N46 Male Infertility
    • N46.0: Azoospermia
      • N46.01: Organic azoospermia
      • N46.02: Azoospermia due to extratesticular causes
        • N46.021: Azoospermia due to drug therapy
        • N46.022: Azoospermia due to infection
        • N46.023: Azoospermia due to obstruction of efferent ducts
        • N46.024: Azoospermia due to radiation
        • N46.025: Azoospermia due to systemic disease
        • N46.029: Azoospermia due to other extratesticular causes
    • N46.1: Oligospermia
      • N46.11:  Organic oligospermia
      • N46.12:  Oligospermia due to extratesticular causes
        • N46.121: Oligospermia due to drug therapy
        • N46.122: Oligospermia due to infection
        • N46.123: Oligospermia due to obstruction of efferent ducts
        • N46.124: Oligospermia due to radiation
        • N46.125: Oligospermia due to systemic disease
        • N46.129: Oligospermia due to other extratesticular causes
    • N46.8: Other male infertility
    • N46.9: Male infertility, unspecified


CPT procedures associate with infertility


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


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


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


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


Coding, Billing, Medical Necessity and Insurance Plan Coverage


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


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


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


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


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


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


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


Operative Records/Clinical Documentation
Included below is an operative report for your review, the CPT codes are those which are actually documented within the report, however, you will note that there is a modifier 59 appended to the chromotubation code.  When these codes were run through the CCI bundling edits, the 58350 was considered “bundled” with the other three codes, however, CCI states that a modifier 59 is permitted if appropriate.   In this operative report, the chromotubation is performed to assess where the blockage is within the fallopian tube.
OPERATIVE REPORT #1
PREOPERATIVE DIAGNOSES: Chronic pelvic pain , endometriosis, infertility .
OPERATION PERFORMED: Operative laparoscopy, lysis of adhesions, right fimbrioplasty, tubal insufflation.
ANESTHESIA: General.
OPERATIVE INDICATIONS AND FINDINGS: 26yo G1P1 with a long history of pelvic pain and known endometriosis with a documented 24 months of infertility.  She underwent an operative laparoscopy a little more than 6 months ago with findings of massive pelvic endometriomas, and endometriosis of the uterus.  Multiple fulgurations were performed and cystectomies.


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


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


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


The right fallopian tube was grasped near its hydrosalpinx and at this point ultimate fusion was identified and using monopolar cautery and scissors.  A small stab wound was made and then the stellate incisions were made from there by both sharp dissection and a little bit of cautery to control bleeding until the distal end of the right fallopian tube lay free.  At this time, the blue dye readily spilled from the right fallopian tube.  The remainder of the implants on the left side underneath where the ovary was adhered,  were fulgurated.  Once this was accomplished, the pelvis was thoroughly irrigated with about 800 cc of Lactated Ringers.  The pelvis was suctioned free and about 2 g of Arista was placed in the lateral pelvic side wall, mostly behind the left ovary to minimize adhesion formation.  The ports were removed and the CO2 was expelled.  The wounds were closed with 4-0 Vicryl sutures, dressed with 2 x 2’s and Opsites.  The patient was awakened and taken to the Recovery Room in good condition.  The estimated blood loss was less than 10 cc.  None was replaced.
CPT Procedure Codes
  • 58672  Laparoscopic Fimbrioplasty
  • 58673-51 Laparoscopic Salpingostomy
  • 58662-51 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
  • 58350-59-51 Chromotubation of oviduct


ICD-10cm Diagnosis Codes :
  • R10.2 Pelvic and perineal pain
  • N97.1 Female infertility of tubal origin
  • N80.3 Endometriosis of pelvic peritoneum
  • N80.8 Other endometriosis (bladder sidewall
  • N73.6 Female pelvic peritoneal adhesions (postinfective)

Operative Report #2


OPERATIVE REPORT: Bilateral vasovasostomy
OPERATIVE DX:  Male Infertility due to vas blockage, inflammation w/ chronic vas pain
OPERATION PERFORMED: Operative vasovasostomy – bilateral
ANESTHESIA: General.


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


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


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


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


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


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


ICD-10cm Diagnosis Codes :
  • N46.023 Azoospermia due to obstruction of efferent ducts
  • R10.2 Pelvic and perineal pain
  • N49.1 Inflammatory disorders of spermatic cord, tunica vaginalis and vas deferens


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Coding Wrap Up


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


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

Lori-Lynne’s Coding Coach Blog

Understanding Bariatric Surgery: CPT and Surgical Interventions

June 19, 2016
 Originally from my HCPro article

In our society, and medical community, the disease of obesity is considered a major health problem. Unfortunately, the disease process of obesity continues to be a major risk factor for the diagnoses in  many other diseases such as diabetes, hypertension, sleep apnea, arthritis, and many, many more.  Obesity is also medically associated with significant morbidity and mortality risk factors when any type of surgical or operative intervention, or even non-surgical hospitalization is necessary.
Most medical providers define and document obesity by the measurement of body mass index (BMI). The BMI is calculated by dividing a patient’s mass (kg) by his or her height (m2). A normal BMI is considered in the range of 18.5-24.9 kg/m2. A BMI of 25-29.9 kg/m2 is considered overweight. A BMI of 30 kg/m2 or greater is classified as obese; this classification is further subdivided into class I, II, or III obesity.  In ICD-10cm, obesity and BMI are now easily identifiable, and should be documented in the patients’ records when obesity is being treated as a stand-alone diagnosis, or as part of a diagnosis with other disease processes that are impacted by obesity.   The ICD-10 codes Z68.xx should be coded in addition to the diagnosis of obesity in the medical record and on your insurance claims. 
Bariatric Surgery Origins
The first effective surgery for obesity in the United States was performed in 1954.  This controversial surgery introduced the jejunoileal bypass.  This “weight loss” surgery was met with controversy, as it did have a large amount of complications, such as extreme malnutrition.   In addition to malnutrition, patients also developed  serious complications secondary to the malabsorption (eg diarrhea, vomiting, eg)  and many required reversal of the bariatric procedure.  These initial complications in the infancy of bariatric medicine, provided the impetus for physicians and surgeons to search for better surgical interventions.  As surgical procedures have progressed and become surgically safer, and with less complications, there has been more acceptance from medical physicians who care for obese patients.  These providers are able to provide better education to the patient,  if a surgical intervention is warranted for morbid obesity diagnoses .   In addition, with better bariatric surgical procedures, especially those that are less invasive,  patients ultimately  have the opportunity for surgical success of elimination of an obesity diagnosis.
Currently, there are four basic concepts/options of choices for patients and physicians to decide upon when moving forward with bariatric surgery:
·         Gastric restriction with adjustable gastric banding  (eg, sleeve gastrectomy)
  • Sleeve gastrectomy
    • In a sleeve gastrectomy, part of the stomach is separated and removed from the body. The remaining section of the stomach is formed into a tube like structure. This smaller stomach cannot hold as much food. It also produces less of the appetite-regulating hormone ghrelin, which may lessen your desire to eat. However, sleeve gastrectomy does not affect the absorption of calories and nutrients in the intestines.
  • Gastric restriction with mild nutritional malabsorption (eg Roux-en-Y gastric bypass)
    • The Roux-en-Y gastric bypass,
      • A  small stomach pouch is created with a stapler device and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration.

  •  “Combination” surgery, that includes both mild gastric restriction and malabsorption (duodenal switch)
    • Sleeve gastrectomy with duodenal switch
      • In this procedure, the physician performs a “sleeve gastrectomy” which includes a duodenal switch.
      • The stomach is resected and “tubulized” with a residual volume of about 150 ml. This gastric reduction is the food intake restriction component.  The stomach itself, is then resected from the duodenum and connected to the distal part of the small intestine.  Once that is completed, the duodenum and the upper part of the small intestine are reattached to the rest at about 75–100 cm from the colon.

·         Laparoscopic adjustable gastric banding
·         “Lap Band” surgery
The laparoscopic adjustable gastric banding procedure, also known as the “Lap Band” surgery,  uses a laparoscopic approach to insert a band containing an inflatable balloon to be placed around the upper part of the stomach then fixed in place. This procedure allows a small stomach pouch to be “created”  above the band with a very narrow opening to the rest of the stomach.

·         A port is then placed under the skin of the abdomen. A tube connects the port to the band. Once in place, the surgeon or physician can adjust the band itself by injecting or removing fluid through the port.  This allows, the balloon to be inflated or deflated to adjust the size of the band, therefore restricting the amount of food that the stomach can hold.  This allows the patient to feel full sooner, but it doesn’t reduce the absorption of calories and nutrients.
As with any of the above generalized components of bariatric surgery, there are many variations to each of the above four main types of surgical intervention.   CPT has done a terrific job of giving coders a wide selection of CPT codes to choose from to describe these surgical interventions.   In addition to the CPT codes, the surgeons have also abbreviated the surgeries as below in this table that the  American Society for Metabolic and Bariatric Surgery (ASMBS) put together as a helpful guide for coders to use.

Open Procedures
VBG
Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
43842
AGB
Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
43843
BPD/DS
Gastric restrictive procedure, with partial gastrectomy, pylorus-preserving duodenoileostomy (50 to 100 cm common channel) to limit absorption (BPD/DS)
43845
RYGB (proximal)
Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (less than 150 cm) Roux-en-Y gastroenterostomy
43846
RYGB (distal)
Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption
43847
Revision RYGB
Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
43848
BPD
Gastrectomy, partial, distal; with Roux-en-Y reconstruction
43633
Laparoscopic Bypass Procedures
RYGB (proximal)
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en Y gastroenterostomy (Roux limb 150 cm or less)
43644
RYGB (distal)
Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43645
Lap DS, Lap revisions
Lap sleeve gastrectomy
Unlisted laparoscopy, stomach
43659
Laparoscopic Gastric Restrictive Procedures
Lap adjustable gastric band and port implantation
Implantation of adjustable gastric band and port, [Laparoscopic]
43770
Lap Sleeve Gastrectomy
Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy)
43775
Let’s take a look at the operative reports
The first operative report is of a traditional laparoscopic sleeve gastrectomy used by CPT code 43775 –  then we have another laparoscopic sleeve gastrectomy that utilized a “robotic” assisted laparoscopic system for the same sleeve gastrectomy.  When coding for these be aware of what “tools” your provider is using if the procedure is being performed as a traditional laparoscopic surgery, or if the physician is utilizing a laparoscopic robotic system.
When coding these, the traditional operation will only require CPT code 43775; however, it you are utilizing a robotic system you should cod the 43775 as your first line item, then add HCPCS code S2900 at $ 0.00 to provide transparency to the codes and inform your insurance payers that the surgery was performed with a robotic laparoscope system.  Be aware that inclusion of the HCPCS code S2900 should not be billed as a stand-alone code, nor is it reimbursable for any extra revenue.  It is simply an “informational” code for the payers.  
Operative Report #1: Laparoscopic sleeve gastrectomy (traditional) 
Operative Report #2: DaVinci MIS (robotic)  laparoscopic sleeve gastrectomy
Operative Report #3: Laparoscopic (Lap-Band) gastric band placement
Operative Report #4: Laparoscopic removal of LAP-BAND, due to pregnancy (enlarged uterus)
As you review these operative reports, you will notice that these are all laparoscopic.  At this time, laparoscopic adjustable gastric banding is considered the least invasive surgical option for morbid obesity.  In addition, the laparoscopic sleeve gastrectomy which is also considered a viable surgical option, is also less invasive than a traditional open procedure with a quicker recovery time.  The Lap Band procedure is potentially reversible.  The laparoscopic sleeve gastrectomy is non-reversable. 
ICD-10 and Bariatric Surgery Status
The ICD-10-CM code Z98.84 Bariatric Surgery Status refers to the presence of any of these type of synonyms used in the clinical documentation of the medical record. 
·         bariatric surgery status 
·         gastric banding status  gastric bypass status for obesity
·         obesity surgery status
  • History of bariatric (weight loss) surgery
  • History of bariatric surgery
  • History of diabetes mellitus resolved post bariatric surgery
  • History of diabetes mellitus resolved post bariatric surgery (situation)
  • History of diabetes mellitus resolved post gastric bypass
  • History of diabetes mellitus resolved post gastric bypass (situation)
  • History of gastric bypass
  • Presence of laparoscopic band/ or presence of laparoscopic gastric banding device
If the patient is pregnant, and the patients’ bariatric surgery status is affecting the pregnancy, the ICD-10-CM refers us to use these codes as outlined below.  However, the physician should be sure to notate that the bariatric surgery status is complicating the pregnancy, and in what matter the complications exist.  The provider should clearly reflect any complications to the pregnancy related to the bariatric surgery status. 
O99.84 Bariatric surgery status complicating pregnancy, childbirth and the puerperium
·         O99.840 Bariatric surgery status complicating pregnancy, unspecified trimester
·         O99.841 Bariatric surgery status complicating pregnancy, first trimester
·         O99.842 Bariatric surgery status complicating pregnancy, second trimester
·         O99.843 Bariatric surgery status complicating pregnancy, third trimester
·         O99.844 Bariatric surgery status complicating childbirth
·         O99.845 Bariatric surgery status complicating the puerperium
As a coder, good documentation from your providers help ensure you are able to clearly code and report the operative session(s), with the diagnosis of obesity and all additional diagnoses that are impacted by the obesity (medical necessity).  All of these criteria go hand in hand with good quality patient care and correct coding and billing of claims. By working closely with your providers, you can ensure good clean claims, and reduce your overall risk of audit inquiry and financial recoupment of paid claim services.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.  
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Operative Report #1
Laparoscopic sleeve gastrectomy (traditional) 
Patient is prepped and all antiembolic precauations are undertaken and appropriate preop antibiotics are administered via IV. A 12-mm optical trocar is placed under direct vision approximately 15 cm below the xiphoid and 3 cm to the left of midline
A 45-degree angled laparoscope is placed through the port into the peritoneal cavity and 12-mm port is placed in the left lateral flank, medial to the edge of the colon with the patient in a supine position and at the same level as the periumbilical port. Next, a 5-mm trocar port is placed along the left subcostal margin between the xiphoid process and the left flank port. Another 12-mm port is placed in the right epigastric region and a fourth 12 mm port was placed in the mid-epigastric region caudal and medial to the previous port. The liver is elevated and this provides adequate visualization of the entire stomach .
The pylorus of the stomach is then identified and the greater curve of the stomach elevated. An ultrasonic scalpel is then used to enter the greater sac via division of the greater omentum. The greater curvature of the stomach is then dissected free from the omentum and the short gastric blood vessels using the laparoscopic ultrasonic scalpel.
The dissection is started 5 cm from the pylorus and proceeds to the Angle of His .  A 9.8 mm gastroscope is then passed under direct vision through the esophagus, stomach, and into the first portion of the duodenum. The gastroscope is aligned along the lesser curvature of the stomach and used as a template to perform the vertical sleeve gastrectomy beginning 2 cm proximal to the pylorus and extending to the Angle of His.
An endoscopic linear cutting stapler is used to serially staple and transect the stomach staying just to the left and lateral to the endoscope. The gastrectomy is visualized with the endoscope during the procedure. The transected stomach, which includes the greater curvature, is completely freed and removed from the peritoneum through the left flank port incision . The staple line along the remaining tubularized stomach is then tested for any leak through insufflations with the gastroscope while the remnant stomach is submerged under irrigation fluid. The staple line is concurrently evaluated for bleeding both intraperitoneally with the laparoscope as well as intraluminally with the gastroscope. A 19-French Blake drain is left in the left upper quadrant along the sleeve gastrectomy staple line. Closure of the fascia t the left flank port site is performed with an absorbable suture on a transabdominal suture passer, to prevent bowel herniation.  We did not close the fascial defects at the remaining port sites.
Patient is taken to PACU in good condition.
CPT code:
43775:  Longitudinal gastrectomy (ie sleeve gastrectomy)


Operative Report #2 
DaVinci MIS (robotic)  laparoscopic sleeve gastrectomy
The Veress needle technique was used to establish the pneumoperitoneum into the left hypochondrium. A 12 mm port was inserted 120 mm inferior and slightly left to the sternum for camera access. For the latter port, we used an extra large 150 mm long trocar The right 12 mm working port was positioned 6 cm from the midline trocar. The left 12 mm working port was located 6 cm to the left of the midline trocar. An 11 mm trocar was placed laterally to the left hypochondrium and an 8 mm da Vinci trocar was placed under the right hip as laterally as possible to allow liver retraction. The 8 mm da Vinci trocars were inserted through standard, disposable 12 mm trocars. This double-cannulation technique was used asstandard 12 mm trocars are required during the insertion of the staples. All trocars are inserted under direct visualization with the da Vinci system camera
We began recording the docking time of the Robot.  The robotic camera was locked last but was used to insert all robotic cannulas and instruments. The robotic cart was positioned over the patient’s head. Once the general setup was ready, the procedure began with myself using a grasper in the left hand and a modified harmonic scalpel in the right hand. The third da Vinci arm used another forceps in order to retract the liver from the 8 mm trocar placed in the right-hand side of the patient. The greater curvature of the stomach was sectioned at the lowest point in order to reach the lesser epiploic sac. During this stage of the procedure, we are completely robotic.   The division of the gastrocolic and gastrosplenic ligament continued exactly as in a standard LSG. With care, we ensure precision in the upper part of the stomach, and avoided any injury to the spleen and had adequate visualization of the vessels. Dissection continued to 5 cm from the pylorus following dissection of the upper part of the stomach.
Next, the assistant surgeon inserted a 32 Fr bougie to calibrate the sleeve. The anesthesiologist did not encounter any difficulty placing the bougie with the robotic bedside cart. A Echelon 60 Endopath stapler, endoscopic linear cutter straight, loaded with a green cartridge, was used to divide the stomach from the lowest tip of the greater gastric curvature;  5 cm proximally to the pylorus, towards the lateral edge of the bougie. This maneuver was performed twice. The right arm was again docked and the left robotic arm was switched to the left lateral 11 mm trocar. This maneuver allowed the decannulation of the right arm from the 12 mm trocar without moving the robot.   We then inserted a stapler loaded with blue cartridges to divide the sleeve up to the end of the upper part. The stomach was then removed from the cavity through the 12 mm trocar. A robotic continuous polypropylene suture (3/0) was used to oversew the entire sleeve staple line.. The first assist then filled the sleeve with diluted methylene blue to detect any leakage from the staple line.  No leaks were encountered, and operative session was complete.  Patient taken to PACU in good condition. 
CPT code:
43775:  Longitudinal gastrectomy (ie sleeve gastrectomy)
S2900: Surgical Techniques Requiring Use Of Robotic Surgical System (List Separately In Addition To Code For Primary Procedure)


Operative Report #3
Laparoscopic (Lap-Band) gastric band placement
The procedure consisted of laparoscopic placement of a gastric band (Lap-Band System), creating a proximal 15-mL pouch at the cardia.
The patient was positioned in an elevated recumbent position. The video monitor was located beyond the patient’s right shoulder.  Pneumoperitoneum was created using a Palmer-Veress needle. The 10-mm optical trocar was inserted first, 10 cm below the xiphoid notch. Then, three 10-mm cannulas were placed under the rib margin.  The fourth cannula on the left had a larger diameter (18 mm) to allow the introduction of the band. All cannulas were then shifted to the left when preoperative (re-review) ultrasound revealed an enlarged left liver lobe (>15 cm high) in the patient. A 10-mm liver retractor was inserted through a paraxiphoid cannula and the left lobe was elevated to expose the cardiac area and the diaphragmatic crus.
Gastric dissection started at the angle of the cardia by division of the phrenogastric ligament. We proceeded with the lap band procedure with a pars flaccida approach on the right side.  Dissection on the left side was identical to that performed on the right. Over the lesser omentum, we opened the peritoneal sheet close to the edge of the right crus, then gradually created a retrogastric tunnel reaching the left crus and the phrenogastric ligament. Thus avoiding tthe use of a balloon.  The band was secured by an anterior gastrogastric valve using four nonabsorbable seromuscular stitches.   .  This covered the anterior part of the band completely. A methylene blue dye test was carried out with no leaks detected.  The subcutaneous port components were then placed and verified as per our pre-operative marking.   Patient was taken to PACU in good condition. 
CPT Code: 43770: Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components)


Operative Report #4
Laparoscopic removal of LAP-BAND, due to pregnancy (enlarged uterus)
INDICATION FOR PROCEDURE:
This is a 27-year-old female who approximately 3 years ago had an adjustable gastric band placed laparoscopically.  She did well and lost over 100 pounds and subsequently became pregnant with twins.  At approximately 22 weeks’ gestation, she started having nausea and vomiting and could not hold food down.  She had some morning sickness in the first trimester, which resulted in multiple bouts of nausea and vomiting, which may have been the etiology of initial slip of her band.  Slip of the band was confirmed during upper GI swallow.  She was referred by Dr.____, with the aforementioned findings requesting in consultation. 
In consultation, it was recommended the band could be put back in place and/or removed, and the patient requested removal of the band.
DESCRIPTION OF PROCEDURE: the abdomen was prepped and draped in the normal sterile fashion, a transverse 1 cm incision was made in the right upper quadrant approximately 1-inch medial to the anterior axillary line and 1 to 1-1/2 inches below the costal margin.  A 5 mm Optiview port was then advanced through the subcutaneous tissue, abdominal wall muscle, and immediately upon advancing through the abdominal wall muscle, encountered the uterine muscle, at which point the blunt trocar was removed.  A different angle tried and subsequently again the uterus encountered.  At this point, an additional incision approximately 2 inches lateral to the incision very near the costal margin was made, and a 5 mm port was able to be placed in the abdomen and insufflated.  Two small muscular lacerations on the right upper portion of the uterus were noted.  Under direct visualization, a 15 mm port was placed in the left upper quadrant directed towards the esophageal hiatus in the midclavicular line approximately 2 cm inferior to the costal margin.  In the epigastrium very near the xiphoid and just deviated to the left, an additional 5 mm port was placed, and a liver retractor was placed, retracting the left lobe of the liver anteriorly.  The patient was placed in reverse Trendelenburg, and a 5 mm port was placed through the original attempted site placement.  All instruments were used in the upper third of the abdomen as the lower two thirds of the abdomen were completely taken up by the very large uterus.  The gastric band tubing was identified, and it was elevated.  Scar tissue of omentum and adipose tissue were divided over this and taken down through the point of the buckle, which was opened.  The band was then adequately freed, the tubing cut, and the buckle opened completely by pulling the tubing through.  The wide part of the locking portion of the buckle, which was anterior, was then divided, which allowed the band to be removed without pressure or difficulty.  It was pulled out through the 15 mm port site in 3 pieces.  The remaining tubing will be pulled out with the subcutaneous port when this is dissected from its left lateral position. 
The ports were then removed under direct visualization, noting no bleeding at any of the port sites.  The liver retractor had been removed prior to moving the ports under direct vision without injury to intraabdominal contents.  The fascia in the 15 mm port site was closed with a figure-of-eight stitch of 0 Monocryl.  The skin directly in the old incision very close to the port was infiltrated with local anesthetic, and a 3 cm incision was made dissecting down and identifying the port.  The port capsule and suture was then dissected free of surrounding tissue and removed along with the port and the tubing.  The skin was then closed at this site with simple interrupted buried sutures of 4-0 Monocryl as was the remainder of the laparoscopic sites.  The skin and all incisions were sealed with Dermabond.
CPT code: 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable
gastric restrictive device and subcutaneous port components

Lori-Lynne’s Coding Coach Blog

Diagnosis Coding for Obesity, BMI, when noted in the clinical record

Diagnosis Coding for Obesity, BMI, when noted in the clinical record
May 20, 2016
As a coder, we are faced with the challenges of reporting all diagnoses held within the medical record that the providers are currently addressing during an encounter with the patient.  The diagnosis of obesity is one of those difficult coding issues.  Obesity is a complicating factor in many areas of health care, and its effect upon care is multifold.    According to the National Institutes of Health (NIH), they define morbidobesity as:
·         Being 100 pounds or more above your ideal body weight.
·         Having a Body Mass Index (BMI) of 40 or greater.
·         Having a BMI of 35 or greater and one or more co-morbid condition.
High-risk comorbid conditions include the diagnoses of; Type 2 diabetes, life-threatening cardiopulmonary problems (egg, severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy), obesity-induced physical problems interfering with a normal lifestyle (e.g., joint disease treatable but for the obesity), and body size problems precluding or severely interfering with employment, family function, and ambulation.
In addition, mental status can also play a part in a patients’ obesity.  Mental status is a difficult diagnosis in and of itself, but can be another diagnosis that will need to be addressed if the physician notes the mental issues such as; severe depression, untreated or undertreated mental illnesses associated with psychoses, active substance abuse, bulimia nervosa, and socially disruptive personality disorders in addition to the obesity.   The Centers for Disease Control (CDC) states that over the last 30 years (as of 2009) that obesity is now considered to be “epidemic” in the United States and in adults 60 years and older is approximately 37% and 34% among women.  
The NIH breaks down obesity into “classes”
Class I Obesity = BMI 30.0 – 34.9 kg/m2
Class II Obesity = BMI 35.0 – 39.9 kg/m2
Class III Obesity = BMI ≥ 40 kg/m2
As a coder, by utilizing the information documented in the record, we can code the BMI from a dietitian’s note, or from the physician’s documentation.  However, if the numeric BMI falls into the “class” status we can report and code this as a Class I, II, or III obesity state.  The obesity documentation still has to be clearly defined within the medical record.  With that, there should be a correlation from the physician to support the obesity code assignment, and how that is currently impacting the patients’ current care and ongoing plan.
The next coding challenge to coding of an obesity diagnosis is the notation of the word “morbid” obesity.   As we know from the NIH, the definition of such is defined, yet many physicians note in the record the words “patient is morbidly obese” but do not include any further information or documentation for the coder to adequately code the obesity diagnosis correctly for that particular patient.  A patient may not have all the criteria for being “morbidly obese” according to the NIH guideline, however, a physician may document that the patient is “morbidly obese” in the medical record.   If the documentation of an obesity diagnosis is a pertinent part of that patients’ care or reason for their medical encounter; the coder is obligated to record the diagnosis accurately and may need to query the provider and ask for clarification or additional information to clearly support the “morbidly obese” diagnosis.  In addition, Coding Clinic, fourth quarter 2005, stated that coders could code BMI based on notes from dietitians, but we should still be diligent in having this information corroborated by the physician in the record too. 
AHIMA has given us a quick tool to use when asking the physician to clarify a diagnosis related to obesity.  In the ICD10cm changes for codes; the listing below helps us give clarity to the physicians, to document what we need to have to clearly report an obesity diagnosis correctly.  In addition, a BMI only identifies the ratio of height to weight and there may be outside factors or other reasons that can alter a BMI “number, such as highly muscular people, pregnant or lactating women.  It is not appropriate to assume or make the correlation that someone is diagnostically obese from a high BMI nor considered diagnostically underweight from a low BMI.
        Obesity
Morbid (severe)
° Due to excess calories
° With alveolar hypoventilation (Pickwickian syndrome)
Drug Induced
° Document drug
Other
° Due to excess calories, familial, endocrine
        Overweight
        Body Mass Index (BMI)
        Document any associated diagnoses/conditions
From a coding perspective, documentation to support a diagnosis of overweight, obesity, and morbid obesity, obesity, should be clearly defined by the physician.  This documentation may include:
Ø  Diet discussed
Ø  Exercise encouraged
Ø  Gastric bypass surgery consult
Ø  Diet medication
Ø  Dietician referral and/or counseling
Ø  Weight loss program (i.e. gym membership)
Ø  Food log
Ø  Physiatrist referral
Obesity and Pregnancy
In April 2016, the American Congress of Obstetricians and Gynecologists (ACOG) defined what they consider obesity to be, and they closely follow the NIH guidelines.  ACOG defines the term “overweight” as having a body mass index (BMI) of 25–29.9.; and define the term “obesity” as having a BMI of 30 or greater.    ACOG has also noted that within the general category of obesity, there are three levels of “risk” go hand in hand with an increasing BMI:
        Lowest risk is a BMI of 30–34.9.
        Medium risk is a BMI of 35.0–39.9.
        Highest risk is a BMI of 40 or greater
ACOG has also confirmed that obesity during pregnancy puts the pregnant female at risk for several serious health problems such as:
        Gestational diabetes:
o   Gestational diabetes that is first diagnosed during pregnancy and can increase the risk of having a cesarean delivery.
o   Women who have had gestational diabetes also have a higher risk of having diabetes in the future, as do their children.
o   Obese women should be screened for gestational diabetes early in pregnancy and also may be screened later in pregnancy as well.

        Preeclampsia:
o   Preeclampsia is a high blood pressure disorder that can occur during pregnancy or after pregnancy.
o   It is a serious illness that affects a woman’s entire body.
o   The kidneys and liver may fail.
o   Preeclampsia can lead to seizures, a condition called eclampsia.
o   In rare cases, stroke can occur.
o   Severe cases need emergency treatment to avoid these complications.
o   The baby may need to be delivered early.
        Sleep apnea: 
o   Sleep Apnea is a condition in which a person stops breathing for short periods during sleep.
o   Sleep apnea is associated with obesity.
o   During pregnancy, sleep apnea not only can cause fatigue but also increases the risk of high blood pressure, preeclampsia, eclampsia, and heart and lung disorders.
        Pregnancy loss—Obese women have an increased risk of pregnancy loss (miscarriage) compared with women of normal weight.

        Birth defects—Babies born to obese women have an increased risk of having birth defects, such as heart defects and neural tube defects.

        Problems with diagnostic tests:
o   Obesity increases the difficulty to visualize and review fetal anatomy on an ultrasound exam.
o   Obesity increases the difficulty to accurately assess the fetal heart rate and/or stress levels during labor

        Macrosomia (a condition in which the baby is larger than normal)
o   Macrosomia can increase the risk of the baby being injured during birth. (e.g. a shoulder dystocia)
o   Macrosomia also increases the risk of cesarean delivery.
o   Infants born with too much body fat have a greater chance of being obese later in life.

        Preterm birth:
o   Problems associated with a woman’s obesity, such as preeclampsia, may lead to a medically indicated preterm birth. (Pre-term birth or pre-term medically necessary induction of labor for a medical reason)
o   Preterm babies are not as fully developed as babies who are born after 39 weeks of pregnancy.
o   Preterm babies have an increased risk of short-term and long-term health problems.
        Stillbirth:
o   The higher the woman’s BMI, the greater the risk of stillbirth.
ICD-10cm Diagnosis Code Changes; BMI reporting
In the ICD-10cm 2016 code set, the codes currently reflect the “new” choices that coders have when reviewing correct coding for “obesity”.   In addition, ICD-10cm now includes codes for obesity that is complicating a pregnancy.   The verbiage “complicating a pregnancy” is critical when determining the correct diagnosis code.  The physician will need do have documented whether the obesity is truly complicating the pregnancy, or if the obesity is simply a status/current state and the patient is incidentally pregnant, and as a coder we cannot assume that correlation.  It is important to remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. 
When coding obesity as a diagnosis, if the BMI is documented in the record, be sure to add that in to your list of diagnoses.  Many insurance carriers are requesting the BMI to be added in conjunction with the obesity codes.  If the patient has presented for an encounter that is in regard to weight management, in coordination with a co-morbid condition be sure to code for all diagnostic co-morbidities.
When sequencing diagnoses for obesity, unfortunately the majority of health insurance plans will not pay for a claim if a code for obesity is listed as the primary diagnosis.   When sequencing obesity codes, review if the patient has other health complaints, such as type II diabetes or heart disease.  If this is the case, and the other health complaints are the primary diagnosisreason for the encounter with obesity as a secondary or tertiary diagnosis this sequencing would be appropriate. 
As a coder, it is your job to confirm the documentation to substantiate what is the primary, secondary and/or tertiary diagnoses are, and that they are clearly reflected in the medical record documentation.   Do not sequence other diagnosis codes before the obesity diagnosis in order to get reimbursed for the claim, especially if the patient is solely there for advice and/or concerns related to their obesity diagnosis. 
In a best practice situation, if the patient is seen for nutritional counseling or consultation with the diabetic educator in regard to their obesity diagnosis, and the patient does not have insurance coverage, inform the patient up-front, and have an ABN signed, or collect at the time of service.  
For drug-induced obesity, documentation should clearly identify the drug that is causing the obesity.  Coding guidelines instruct the coder to include an additional code to identify the drug causing the obesity, when known. This will result in the selection of a code from the range T36–T50, which should be sequenced after the obesity code.
In scenario #1, it is appropriate to code the diabetes diagnosis as primary; however, in scenario #2 the obesity is the primary diagnosis. 
Case Example #1: A female patient with type II diabetes without complications presents to the office for nutritional counseling.  She is 32 years old and was recently diagnosed with DMII, and is worried about her health.  She is morbidly obese and admits that she overeats. Her BMI is 36.
ICD-10cm Codes:
o   E11.9, Type 2 diabetes mellitus without complications
o   E66.01, Morbid (severe) obesity due to excess calories
o   Z71.3, Dietary counseling and surveillance
o   Z68.36, Body mass index (BMI) 36.0-36.9, adult
Case Example #2: A female patient with severe allergies, due to the steroid Decadron, presents to the office today for nutritional counseling in regard to her weight gain from the steroid.  She is no longer on the steroid and discontinued two months ago.   She is 32 years old and had been on the steroid for 60 days with a 30 day taper.   She is worried about her 15 pound weight gain.  In addition, pt.’s weight was stable at 155 prior to the Decadron. Her weight today is 170 Her BMI is 30.
ICD-10cm Codes:
o   E66.1, Drug Induced Obesity
o   T38.OX5S Adverse effect of glucocorticoids and synthetic analogues sequela
o   Z71.3, Dietary counseling and surveillance
o   Z68.30, Body mass index (BMI) 30.0-30.9, adult
Case Example #3:  Pt is admitted to the L&D unit for extreme obesity with a mild pre-eclampsia to ensure fetal wellbeing.  Pt is currently 37 weeks plus 2 days.  Fetal presentation is complete breech. Weight 165 lbs., height 149.86cm, her calculated BMI is 48, category III Obesity.  Due to extreme obesity in pregnancy, twice daily NST’s to be performed as part of the clinical management to ensure stable fetal status and will observe the mild preeclampsia.  Coordinate care with dietician; Blood Glucose (non-fasting) was 96.  No current indication of Gestational Diabetes. Continue management for mild preeclampsia and consider induction upon NST reviews and pre-eclampsia progression.
ICD-10cm Codes:
o   O14.03      Mild to moderate pre-eclampsia, third trimester
o   O99.213    Obesity complicating pregnancy, third trimester
o   Z3A.37     37 weeks gestation of pregnancy
o   O32.1xx1  Maternal care for breech presentation
o   Z71.3         Dietary counseling and surveillance
o   Z68.41       Body mass index (BMI) 40.0-44.9, adult
Final thoughts – wrap it up neatly
As a coder, the correct diagnosing and sequencing of obesity and obesity complications is an obligation that you must take seriously when applying codes to the patients’ medical record.  An inadvertent error of a diagnosis of obesity can have multiple long-range affects to the patient’s current and on-going care.  If records are reviewed, and an incorrect diagnosis of obesity or an incorrect BMI documentation is in the record, this may preclude a patient from obtaining, medial or life insurance, and even possibly affect their financial status when obtaining a loan or monetary transactions.  Some employers even require a patient to disclose medical information prior and/or post hire.  
Correct clinical documentation in regard to obesity needs to be clear, concise and show disease correlation when appropriate.  If those items are not readily interpreted within the record, query the provider to provide clarity.   Full listings of all obesity codes are contained in the ICD-10cm code set as are the formal coding guidelines.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.  
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Below is the current listing of the ICD-10cm code set for obesity and overweight coding:
Overweight, obesity and other hyperalimentation (E65-E68)
E65 Localized adiposity Fat pad
E66 Overweight and obesity Code first obesity complicating pregnancy, childbirth and the puerperium, if applicable (O99.21-)
Use additional code to identify body mass index (BMI), if known (Z68.-)
Excludes1: adiposogenital dystrophy (E23.6) lipomatosis NOS (E88.2) lipomatosis dolorosa [Dercum] (E88.2) Prader-Willi syndrome (Q87.1)
E66.0 Obesity due to excess calories
E66.01 Morbid (severe) obesity due to excess calories
Excludes1: morbid (severe) obesity with alveolar hypoventilation (E66.2)
E66.09 Other obesity due to excess calories
E66.1 Drug-induced obesity
Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)
E66.2 Morbid (severe) obesity with alveolar hypoventilation Pickwickian syndrome
E66.3 Overweight
E66.8 Other obesity
E66.9 Obesity, unspecified Obesity NOS
Pregnancy Obesity Codes
O99.2 Endocrine, nutritional and metabolic diseases complicating pregnancy, childbirth and the puerperium
O99.21 Obesity complicating pregnancy, childbirth, and the puerperium
O99.210 Obesity complicating pregnancy, unspecified trimester
O99.211 Obesity complicating pregnancy, first trimester
O99.212 Obesity complicating pregnancy, second trimester
O99.213 Obesity complicating pregnancy, third trimester
O99.214 Obesity complicating childbirth
O99.215 Obesity complicating the puerperium
Body mass index [BMI] Z68- >
Applicable To Kilograms per meters squared
Note:  BMI adult codes are for use for persons 21 years of age or older BMI pediatric codes are for use for persons 2-20 years of age. These percentiles are based on the growth charts published by the Centers for Disease Control and Prevention (CDC)
 Z68 Body mass index [BMI]
Z68.1 Body mass index (BMI) 19 or less, adult
Z68.2 Body mass index (BMI) 20-29, adult
Z68.20 Body mass index (BMI) 20.0-20.9, adult
Z68.21 Body mass index (BMI) 21.0-21.9, adult
Z68.22 Body mass index (BMI) 22.0-22.9, adult
Z68.23 Body mass index (BMI) 23.0-23.9, adult
Z68.24 Body mass index (BMI) 24.0-24.9, adult
Z68.25 Body mass index (BMI) 25.0-25.9, adult
Z68.26 Body mass index (BMI) 26.0-26.9, adult
Z68.27 Body mass index (BMI) 27.0-27.9, adult
Z68.28 Body mass index (BMI) 28.0-28.9, adult
Z68.29 Body mass index (BMI) 29.0-29.9, adult
 Z68.3 Body mass index (BMI) 30-39, adult
Z68.30 Body mass index (BMI) 30.0-30.9, adult
Z68.31 Body mass index (BMI) 31.0-31.9, adult
Z68.32 Body mass index (BMI) 32.0-32.9, adult
Z68.33 Body mass index (BMI) 33.0-33.9, adult
Z68.34 Body mass index (BMI) 34.0-34.9, adult
Z68.35 Body mass index (BMI) 35.0-35.9, adult
Z68.36 Body mass index (BMI) 36.0-36.9, adult
Z68.37 Body mass index (BMI) 37.0-37.9, adult
Z68.38 Body mass index (BMI) 38.0-38.9, adult
Z68.39 Body mass index (BMI) 39.0-39.9, adult
 Z68.4 Body mass index (BMI) 40 or greater, adult
Z68.41 Body mass index (BMI) 40.0-44.9, adult
Z68.42 Body mass index (BMI) 45.0-49.9, adult
Z68.43 Body mass index (BMI) 50-59.9 , adult
Z68.44 Body mass index (BMI) 60.0-69.9, adult
Z68.45 Body mass index (BMI) 70 or greater, adult
Z68.5 Body mass index (BMI) pediatric
Z68.51 …… less than 5th percentile for age
Z68.52 …… 5th percentile to less than 85th percentile for age
Z68.53 …… 85th percentile to less than 95th percentile for age
Z68.54 …… greater than or equal to 95th percentile for age

Lori-Lynne’s Coding Coach Blog

Zika Virus – A Q&A Primer – Info on Zika is changing quickly – here’s what I know as of today (03/02/2016)

This is the most current article that I wrote for Justcoding.com.  It is also free to access on their website.  However, I suggest becoming a full-subscription member, as they have a huge amount of resources and information available.  🙂 


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Zika Virus –  A Q&A Primer
by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP
What is Zika?
According to the Center for Disease Control (CDC)  this is the officialdefinition:
The Zika virus is a mosquito-transmitted infection related to dengue, yellow fever and West Nile virus. It was discovered in the Zika forest in Uganda in 1947 and is common in Africa and Asia.  It did not begin spreading widely in the Western Hemisphere until last May, when an outbreak occurred in Brazil.
A bit of clinical background
This is information direct from the American Congress of Obstetricians and Gynecologists (ACOG)  and the Society of Maternal and Fetal Medicine  (SMFM)
The virus spreads to humans primarily through infected Aedes aegyti mosquitoes. Once a person is infected, the incubation period for the virus is approximately 3-12 days. Symptoms of the disease are non-specific but may include fever, rash, arthralgias, and conjunctivitis. It appears that only about 1 in 5 infected individuals will exhibit these symptoms and most of these will have mild symptoms. It is not known if pregnant women are at greater risk of infection than non-pregnant individuals.
Zika during pregnancy has been associated with birth defects, specifically significant microcephaly. Transmission of Zika to the fetus has been documented in all trimesters; Zika virus RNA has been detected in fetal tissue from early missed abortions, amniotic fluid, term neonates and the placenta. However, much is not yet known about Zika virus in pregnancy. Uncertainties include the incidence of Zika virus infection among pregnant women in areas of Zika virus transmission, the rate of vertical transmission and the rate with which infected fetuses manifest complications such as microcephaly or demise. The absence of this important information makes management and decision making in the setting of potential Zika virus exposure (i.e. travel to endemic areas) or maternal infection, difficult. Currently, there is no vaccine or treatment for this infection.
The ACOG and SMFM put forth guidelines for testing of pregnant women, and the laboratory tests are being done exclusively though the guidance of the CDC at the level of the local and state health departments.  Many states in the US are developing guidelines to help in identifying who has been exposed, and where an outbreak may take place. 
Currently the testing being done is a “Zika” serology IgM testing assay.  The reports have been being reported out as “likely positive”, “Inconclusive” and “likely negative”  .  Unfortunately, the labs do not know and gannot guarantee the sensitivity of the IgM assay.
Symptoms of Zika
 Below is a listing of all the known symptoms of Zika virus as put forth by the CDC, however, there may be more that are noted as the Zika Virus becomes more studied in all individuals. Zika is still a virus, and not a bacterial infection, and currently there is not vaccine to prevent it, or a specific medication or antibiotic to treat it with. 
• About 1 in 5 people infected with Zika virus become ill (i.e., develop Zika).

• The most common symptoms of Zika are fever, rash, joint pain, or conjunctivitis (red eyes). Other common symptoms include muscle pain and headache. The incubation period (the time from exposure to symptoms) for Zika virus disease is not known, but is likely to be a few days to a week.
• The illness is usually mild with symptoms lasting for several days to a week.
• People usually don’t get sick enough to go to the hospital, and they very rarely die of Zika.
• Zika virus usually remains in the blood of an infected person for about a week but it can be found longer in some people.
Risks of Zika in Pregnant Women and in their sexual  partners
Normally Zika virus is transmitted through a mosquito bite, however, the Zika virus can be transmitted from a pregnant mother to her unborn fetus during the time of pregnancy and possibly around the time of birth.  It has been noted that Zika virus has been noted in all trimesters of pregnant women, and may possibly be transmitted during the birth process.  Sexual transmission of the Zika virus can also occur, however there is limited data, but the CDC has stated that if the patient fears they are infected with the Zika virus to reduce the risk of sexual transmission via abstinence and/or usage of condoms.
Women are not the only ones at risk of contracting Zika virus.  Men who have traveled to an area of active Zika virus, or who live in these areas may become infected with the Zika virus too.  The CDC has not completely determined if the Zika virus can be transmitted sexually, so the recommendation for men is if you are symptomatic or have a confirmed case of Zika virus, condoms or abstinence is still a best practice.  However, it remains uncertain if the mirus persisits in semen even if no longer  detectible in the blood.
Fetal Evaluation for possible exposure to Zika
Ultrasound exami is the primary recommendation for pregnant mothers who have been exposed to zika virus.  The Ultrasound examinations should focus on development of the fetal brain with intracranial calcifications and microcephaly.  Micocephay has been the most frequently reported adverse fetal complication  in women who have had the virus while pregnant
SMFM is recommending not only blood tests for pregnant women who have been exposed, but also consider performing serial ultrasound, as frequently as every 3-4 weeks.   By obtaining the additional ultrasounds, this would be considered ongoing surveillance.  Considering the history of Zika virus and complications to the fetus  due to this infection is not known.  In addition,  the time from exposure and infection from Zika  to  exhibiting full-blown clinical manifestations is unknown.
The CDC, ACOG and SMFM have put out a number of clinical flow algorhythms for usage with patients’ that have been exposed or live in an area where Zika as been prevalent.  However, this is so new, that these recommendations may change very quickly.   
Case Study and Coding Consideration
Case #1:
An asymptomatic pregnant woman at 19 weeks gestation, presents to her OB office for her regularly scheduled OB prenatal visit.  She informs the receptionist of the possibility she has been exposed to Zika. She has a history of travel to Mexico between 16+0 and 16+5-weeks. She has noted mosquito bites over both legs (calf area).  The bites do not appear infected, and look as if they are resolving.  Patient states they no longer itch, and does not report any other complaints but her ongoing pregnancy related fatigue.  The physician performs a comprehensive history, a comprehensive exam, and will have labs drawn for Zika to be sent to the local district health office.  In addition, the physician decides to perform a baseline screening ultrasound exam to follow up from the patient’s first trimester ultrasound anatomy exam from 1 month ago. 
Coding Consideration: 
CPT: 
99214-25 E&M  – 
76816 Ultrasound 
36415 Venipuncture/Lab Draw
ICD-10: 
O26.812   Pregnancy related exhaustion and fatigue (2ndtrimester)
Z20.828    Contact with and (suspected) exposure to other viral communicable        diseases (Zika Virus)
S80.861A  Insect bite of rt lower leg initial encounter
S80.862A  Insect bite of lt lower leg initial encounter
Z3A.19      19 weeks gestation of pregnancy
Rationale:  The  E&M visit would be coded, as it is separately identifiable  “outside” the normal pregnancy antenatal care.  (A Zika virus exposure is not considered “normal obstetric care”)  the follow-up ultrasound/baseline ultrasound is coded for comparison to the previously performed 1st trimester ultrasound.  The venipuncture is the only thing chargeable, as the blood was drawn, and sent out to the health district for testing.  The sequencing of the pregnancy diagnosis is primary based upon the ICD-10 pregnancy guidelines.
ACOG’s Quick Zika Q&A
Q1.  True or False. Pregnant women are at greater risk of infection with the Zika virus than nonpregnant women.
A:   False – According to a practice advisory from ACOG and SMFM, “It is not known if pregnant women are at greater risk of infection than non-pregnant individuals.”
Q2.  Once a person is infected with the Zika virus, what is the approximate incubation period for the virus?
A:.   3 to 12 days – Following infection with the Zika virus, the incubation period is approximately 3 to 12 days
Q3.  The Zika virus spreads to humans primarily through infected Aedes aegypti mosquitoes. Which of the following symptoms may be associated with the virus?
Fever
Rash
Arthralgia
Conjunctivitis
All of the above       
A.   Although symptoms associated with the Zika virus are non-specific, they may include fever, rash, arthralgia, and conjunctivitis. (eg all of the above)
Q4. In which trimester(s) has transmission of Zika been documented?
A. All trimesters — The transmission of the Zika virus has been documented in all trimesters
Wrap up
At this time, there are still a number of unanswered questions in regard to the Zika virus.  However, there is no vaccine currently available, so it is recommended that precaution be taken to avoid exposure to mosquito bites from areas where the Zika virus is prevalent.  In the United States and worldwide expert epidemiologists are helping to set forth useful clinical guidelines for identifying and managing patients who have been exposed and currently have the Zika virus.  At this time, clinical guidelines are calling for blood tests to be run, and screening ultrasound should be performed on pregnant patients to screen for possible fetal anomalies related to fetal brain development in infected female patients.
When coding, carefully review to see if the physician or provider is stating whether the patient truly has the Zika virus as a diagnosis, or if they are only “screening” for the Zika virus in light of an exposure to the virus. (either through mosquito bite, or sexual transmission).  
In addition, currently, ICD-10 does not have a specific code to identify Zika virus. Usage of code B33.8 Other specified viral diseases, would be appropriate.  However, If the patient is diagnosed with the Zika virus and has fever with it, then it may be appropriate to use code A92.8 – Other specified mosquito-borne viral fevers.   If the patient is pregnant, then usage of ICD-10 code 098.5X “other viral diseases complicating pregnancy, childbirth and the puerperium,” (be sure to use the most specific trimester as the additional character) would be the most appropriate. 
If in doubt about the clinical documentation, be sure to query the provider to obtain clarity on the diagnosis noted in the medical record. 
References:
www.acog.org/
www.cdc.gov/zika
Editor’s note: 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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