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Reimbursement Advisor


Reimbursement Adviser on the Web

April 2007 · Vol. 19, No. 04

Is injectable contraceptive “medical necessity”?

<huc>Q.</huc> One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

<huc>A.</huc> Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

<huc>Q.</huc> I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

<huc>A.</huc> Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

<huc>Q.</huc> What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

<huc>A.</huc> To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

  • Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  • Other specified complications of pregnancy (646.83)
  • Other specified indications for care or intervention related to labor and delivery (659.8X)
  • No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).

Get reimbursed for counseling absent patient?

<huc>Q.</huc> What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

<huc>A.</huc> This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

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