Using new ICD-9 codes for everyday dilemmas
Initial OB visit, preop exams, multiple gestation reduction, low-risk HPV, obesity, history of UTIs…many more
Quick reference: ICD-9-CM updates online www.obgmanagement.com
How do you prevent a “missed period” visit from being incorrectly assigned to the global obstetric package?
Sandra has missed her period and suspects she may be pregnant. You examine her and perform a urine pregnancy test, which confirms the gestation. After giving her a prescription for vitamins and a lab slip for prenatal testing, you ask her to make an appointment in 2 weeks to begin prenatal care.
Now we have a new code (V72.42, pregnancy examination or test) to report the first encounter with the patient at which pregnancy is confirmed. Before the latest batch of new codes, which took effect October 1, the American College of Obstetricians and Gynecologists (ACOG) recommended using ICD-9-CM code 626.8 (missed period) for this office visit, though the “missed period” code implied disease rather than pregnancy. ICD-9-CM rules mandate coding for what is known at the end of a visit. Previously, codes V22.0 or V22.1 (supervision of normal pregnancy) were the only choices.
This pregnancy is not yet being supervised. The visit to confirm pregnancy now will generally be a low-level evaluation and management (E/M) service and is billed outside the global obstetric package because the patient’s pregnancy is not yet being supervised. The new code V72.42 makes this clear.
Changes for the better
That’s just one of the welcome diagnostic code additions in the International Classification of Diseases–9th Edition–Clinical Modification, thanks to the efforts of ACOG.
Besides the new code for pregnancy confirmation, there are codes for:
- multiple pregnancy that has been reduced in number
- expanded genetic counseling and testing
- oocyte donor, blood typing, and other pregnancy-related codes abnormal Papanicolaou smear has simpler wording.
- 2 codes designate cancer therapy: chemotherapy or immunotherapy
- family history of osteoporosis
- personal history of urinary tract infections
- tracking overweight and obese patients
…to name just a few.
What is the best way to code low-risk HPV?
Greta, 42, undergoes cervical sampling by the Papanicolaou test and human papillomavirus (HPV) test; the latter is positive for low-risk HPV types.
Code 795.09, other abnormal Papanicolaou smear of cervix and cervical HPV, has been revised slightly. The example of when to assign this code now reads “cervical low-risk human papillomavirus (HPV) DNA test positive.”
Simpler wording. This revision has simplified the wording of the example, clarifying its use, and does not change how the code is reported.
PHYSICAL EXAM PRIOR TO PROCEDURE
How do you distinguish preop exams from specialized exams of a specific area or system?
Rachel, 42, is scheduled to undergo uterine artery embolization for fibroids, and you perform the preoperative examination.
V72.83, other specified preoperative examination, and V72.84, preoperative examination, unspecified, have been revised to clarify that they should be reported when a general physical examination was performed prior to surgery or a procedure.
History of specific problems
Several codes have been added to allow ObGyns to use more specific history information relating to the patient’s condition or concerns:
- V13.02, personal history of urinary (tract) infection
- V15.88, personal history of fall or risk for falling
- V17.81, family history of osteoporosis
- V18.9, family history of genetic disease carrier.
What code indicates overweight necessitating intervention?
Alisha is 32 and weighs 180 lb, a heavy load for her 5 ft 2 inch frame. She reports that her health insurance will cover her membership costs for any 1 of several weight loss programs, provided she can demonstrate that she is significantly overweight.
The concerns of the medical community about the increasing prevalence of overweight and obesity (and, more rarely, underweight) and the link to many disease conditions has prompted ICD-9-CM to add several new codes for reporting a woman’s weight.
Supports insurance claims? Code 278.02, overweight, was added and linked to the new codes that report the patient’s body mass index (BMI). The national standards classify a patient as underweight, normal, overweight, obese, or morbidly obese based on the documented BMI; this information may assist patients in receiving treatment for their obesity through insurance coverage.
To calculate BMI, multiply weight in pounds by 703/height in inches squared. The ideal BMI is 20 to 25. Underweight patients have a BMI of 19 or less.
Before the new code for overweight can be entered in Alisha’s case, her BMI would need to be documented at 25 or above. Since her BMI is 32.9, she would fall into the obese category, which includes BMIs of 30 to 34.9. Someone who is morbidly obese has a BMI of 40 or more, or a BMI of more than 35 with 1 or more comorbid conditions such as hypertension, heart disease, high cholesterol, diabetes, severe joint pain, or arthritis.
The new BMI codes (V85.0–V85.4) are reported for any adult older than 20. Next year, codes will be added for patients who are between 2 and 20 years of age.
Should a pregnancy be coded differently after a fetal reduction procedure?
Mariana, 40, undergoes in vitro fertilization with implantation of 2 embryos, but later, because of her age and health (she has metabolic syndrome), requests fetal reduction for a singleton gestation.
Multifetal pregnancy reduction is billed using CPT code 59866, and we now have a new ICD-9-CM code to characterize such gestations after the procedure: 651.7X, multiple gestation following (elective) fetal reduction.
The last digit can be 0, episode of care unspecified; 1, delivered with or without mention of antepartum condition; or 3, antepartum condition or complication.
High risk remains. Though fetal reduction will generally reduce risk to the remaining fetuses, the pregnancy is still considered high-risk. ICD-9-CM staff have clarified that this code should be reported even if, as in Mariana’s case, the pregnancy is reduced to a singleton gestation, as fetal reduction is a complicating factor.
ABNORMAL GLUCOSE TOLERANCE
Is there a specific code for elevated glucose tolerance test?
At 28 weeks’ gestation, Rebecca reports symptoms suggesting hyperglycemia, so you order blood glucose testing, which reveals elevated glucose tolerance.
Code 648.8X, abnormal glucose tolerance, has been revised to include conditions classifiable as 790.21 through 790.29, and a note was added to report V58.67 for associated long-term (current) insulin use.
Codes 790.21 through 790.29 are used to report specific abnormal glucose findings and may be added as a secondary diagnosis to clarify the abnormal result in pregnancy. For instance, code 790.21 is reported if the patient has elevated fasting glucose, while 790.22 indicates she has an elevated glucose tolerance test, as in Rebecca’s case.
Other pregancy-related codes
Obstructed labor. In other pregnancy-related changes, ICD-9-CM has clarified use of 660.8X, other causes of obstructed labor, to require an additional code to identify the cause. For instance, if the internal orifice is total obstructed by a tumor, use code 660.8X as the primary diagnosis and 653.8X, disproportion of other origin.
Procreative management. V59.7, donor, egg (oocyte) (ovum) has been added, and includes five 5-digit codes for type of donor. Using them properly requires knowing the age and status (eg, anonymous or not) of the donor. If no information about the donor’s age is available, the unspecified code V59.70 is used. Otherwise the choices are V59.71 and V59.73 for anonymous donors under age 35 and 35 and over, respectively, and V59.72 and V59.74 for donors under age 35 and 35 and over, respectively, whose eggs are to go to a designated recipient.
Blood typing. V72.86, encounter for blood typing, now can be used to report testing of the father when the mother is Rh-negative. This information allows physicians to determine the risk of Rh sensitization in the fetus and decide whether immunoglobulin administration is necessary to prevent it during the remainder of the pregnancy.