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Reimbursement Advisor

2008 codes include means to specify severity of dysplasia

New and updated codes cover VIN, traumatic delivery, natural family planning, catheter infections, more

September 2007 · Vol. 19, No. 09
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Save the date! Important ObGyn revisions to the International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) take effect October 1. Take note of these additions and modifications to ensure that you’re maximizing your reimbursement on claims.

Vaginal, vulvar conditions: Simpler reporting

This year’s additions include codes for vaginal intraepithelial neoplasia (VAIN) and expansion of the vulvar intraepithelial neoplasia (VIN) category to match.


Vulvar intraepithelial neoplasia I [VIN I]


Mild dysplasia of vulva


Vulvar intraepithelial neoplasia II [VIN II]


Moderate dysplasia of vulva


Other dystrophy of vulva


Kraurosis of vulva


Leukoplakia of vulva


Unspecified female genital organ




Severe dysplasia of vagina


Vaginal intraepithelial neoplasia III [VAIN III]




Severe dysplasia of vulva


Vulvar intraepithelial neoplasia III [VIN III]


Other female genital organ

Until now, you have had only three codes to work with: 623.0 [dysplasia of vagina]; 624.0 [dystrophy of vulva]; and 233.3 [Ca in situ of other and unspecified genital organs]. Pathology reports often support higher specificity of coding, however, which makes it easier to establish medical necessity for further diagnostic testing or surgical intervention. Beginning October 1, the new codes specify the severity of dysplasia, so you will need to be more exact about the patient’s condition. In addition, 623.0, the established code for vaginal dysplasia, now specifically references both VAIN I and II.

An “excludes” note has also been added to 622.1 [dysplasia of cervix (uteri)] to clarify that a diagnosis of carcinoma in situ I or II may not be reported unless this diagnosis is assigned based on a biopsy finding—not on an abnormal finding on a Pap smear.

New code for trauma during delivery

Anal sphincter tears can occur during delivery without an accompanying third-degree perineal laceration, so a new code [664.6X, anal sphincter tear complicating delivery, not associated with third-degree perineal laceration] has been added to capture this information. Keep in mind these important points:

  • Report the new code when an anal tear is noted at or after delivery. The only acceptable fifth digits for this code are 0 [unspecified as to episode of care or not applicable], 1 [delivered, with or without mention of antepartum condition], or 4 [postpartum condition or complication].
  • Report the established code, 664.2X [third-degree perineal laceration] if an anal tear is noted in addition to a third-degree perineal tear. The fifth digit will be 0, 1, or 4, as it is with the code for an anal sphincter tear.
  • Report the established code 654.8X [congenital or acquired abnormality of vulva] if the patient had an anal tear from a prior pregnancy, before the current delivery.
  • Last, report the new code 569.43 [anal sphincter tear (healed) (old)] if you observe that the patient has an old anal tear but isn’t pregnant. Report an additional code for any associated fecal incontinence (787.6).

Anal tears can complicate the next delivery and are responsible for fecal incontinence—a finding that may lead to a diagnosis of an old, unhealed anal sphincter tear. Remember that, for this coming year, you have to document the circumstance to report the correct code.

Report dysplasia follow-up as “medical necessity”

Once a patient has been treated for cervical dysplasia, long-term follow-up care is required to test for recurrence. The only code available to report that history last year was V13.29, a general code that reported all types of genital systems and obstetric disorders. This year, you can specify and report V13.22 [personal history of cervical dysplasia].

The role of human papillomavirus (HPV) as the cause of cervical cancer is well known, and routine screening tests for this infection are generally as accurate as a routine Pap smear. Because of this, a new code, V73.81 [human papillomavirus (HPV)], has been added to document encounters for HPV screening. The new code can be reported in conjunction with the routine gyn exam code, V72.31, or V76.2 [special screening for malignant neoplasm of cervix] to signal that additional screening is planned.

Better documentation of malignant ascites

789.51  Malignant ascites

789.59  Other ascites

Malignant ascites is seen most often in ovarian, endometrial, breast, colon, gastric, and pancreatic cancer. Management of this condition may include systemic chemotherapy, instillation of radioisotopes or chemotherapy drugs into peritoneal fluid, and peritoneal–venous shunting procedures.

Before October 1, under ICD-9 rules, malignant ascites could be reported only using the code 197.6 [secondary malignant neoplasm of retroperitoneum and peritoneum].The problem is that this condition can also be caused by a primary ovarian malignancy, for which there has been no reporting mechanism. With expansion of the code 789.5 [ascites], you can specify the type of malignant ascites.

Note: Instructions in ICD-9 indicate that you should list a code for the site of the current malignancy first, such as 183.0 [malignant neoplasm of ovary] or 197.6 [secondary malignant neoplasm of retroperitoneum and peritoneum].

Assisted reproductive fertility procedure status

Every endocrinologist is aware that assisted reproductive fertility procedures are a multistage undertaking. A number of pretreatment diagnostic tests are independent of the procedure itself, and payers might cover such tests if there were a way to identify patients who were undergoing a procedure from those who were still undergoing pretreatment testing.

Before October 1, only one code, V26.8 [other specified procreative management], was available. Starting this month, to identify a patient undergoing treatment, use V26.81 [encounter for assisted reproductive fertility procedure cycle], with an additional code to identify the type of infertility. With this expansion, a second code was added to capture “other specified procreative management” [V26.89].

Natural family planning comes of age

Natural family planning helps a couple determine when sexual intercourse is likely to (and not likely to) result in pregnancy. It encompasses provider counseling and education on either of two acceptable methods: tracking ovulation by examining cervical mucus or temperature charting. ICD-9 has expanded the existing code, V26.4, to capture this means of family planning more accurately:

V26.41  Procreative counseling and advice using natural family planning

In addition, a code was added to the contraceptive counseling codes to capture this approach as well:

V25.04  Counseling and instruction in natural family planning to avoid pregnancy

Last, a new code also covers other types of procreative management counseling and advice:

V26.49  Other procreative management counseling and advice

Disability certificates, made easy(ier) to report

Do patients come to you to have medical forms and certificates completed? Now you can be more specific, when coding, about the type of document you’re asked to fill out.

V68.01  Disability examination

V68.09  Other issue of medical certificates

The old code, V68.0, was a catch-all of medical certificates, including cause of death, fitness, and disability. The new codes distinguish a certificate for a disability examination from the rest of the pack. That’s a useful change because insurers and state disability programs often reimburse for a disability exam.

Remember: You still need to identify the specific exam, screening, or testing performed by using a code from the series V72.0V82.9 as a secondary diagnosis. Examples: V72.31 for a gyn exam and V81.6 [screening for other and unspecified genitourinary conditions].

Diversified codes for iatrogenic ID complications

Patients sometimes develop infection in the presence of a central venous catheter or after injection or vaccination. Previously, you used code 999.3 to report such a complication, but that code lumped into one all reasons for infection.

This year, a new code, 993.31, exclusively covers infection caused by a central venous catheter. The code lists several catheter types—Hickman, peripherally inserted central catheter (PICC), triplelumen catheter—and makes clear that it should not be used to report infection caused by a urinary (996.64), arterial (996.62), venous (996.62), or unspecified type of catheter (996.69).

An additional code, 999.39, has been added to report all infections after intravenous infusion, injection, transfusion, or vaccination.

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