Coding Strategy

Bonus: Get exposure to ICD-10 coding equivalents.

Question: A mentally-challenged patient who delivered at home was admitted to the hospital for postpartum care. The patient delivered the placenta at home, and once admitted, she had no complications, but the ob-gyn did perform a first degree laceration repair. I’m not sure what diagnosis code to report. Should I look at routine postpartum care or pregnancy complications? And if I use a complication code, what would the fifth digit to a “1″ or “0?”

Texas Subscriber

Answer: Under most situations where the ob-gyn treated no problems during the admission, you would code V24.0 (Postpartum care and examination; immediately after delivery) on the admission date and V24.2 (Routine postpartum follow-up) for any subsequent routine care.

But in this case, your physician also repaired a first degree laceration (CPT code 59300, Episiotomy or vaginal repair, by other than attending physician). Therefore, you may consider this to be an admission for a postpartum condition and instead report 664.04 (First degree perineal laceration). The fifth digit cannot be “1″ or “0″ because the patient delivered prior to her admission and of course you know her delivery status. In this case, the fifth digit must be “4″ to indicate a purely postpartum condition. You may optionally report V24.0 and V24.2 as your secondary diagnoses, but they are not required in this case.

ICD-10: In the near future, you will replace ICD-9 codes V24.0 and V24.2 with ICD-10 codes Z39.0 (Encounter for care and examination of mother immediately after delivery) and Z39.2 (Encounter for routine postpartum follow-up), respectively. Code 664.04 will be replaced by O70.0 (First degree perineal laceration during delivery).

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Don’t forget to include the code for the arthrocentesis.

Question: A new patient sees the orthopedist because of shoulder problems. The physician schedules an MRI and the patient returns the following week to discuss the findings. The physician had already reviewed the films and goes over them in depth with the patient. He also administered a shoulder joint injection to help relieve the patient’s pain.

What diagnosis should we report with the E/M service to reflect the amount of time spent reviewing films and counseling the patient and to distinguish it from the injection?

West Virginia Subscriber

Answer: Select a diagnosis based on your provider’s documentation, such as rotator cuff tear (840.4, Sprains and strains of shoulder and upper arm; rotator cuff [capsule], or 727.61, Rupture of tendon, nontraumatic; complete rupture of rotator cuff). Include that diagnosis with …

… the appropriate E/M code for your physician’s service (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Also report 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) with 719.41 (Pain in joint; shoulder region) for the shoulder injection.

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No severe problems? You may have trouble with reimbursement.

Question: The ob-gyn performed and OB ultrasound (US) on a patient. Can I bill 76376 in addition to the ultrasound if the ob-gyn used 3D?

Montana Subscriber

Answer: Yes. You can report a 3D procedure with 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks 0 days], transabdominal approach; single or first gestation) and 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation).

However, getting it paid is another matter. If your ob-gyn is performing 3D ultrasounds, she should warn the patient that her payer may not reimburse for it, and the patient will have to pay out of pocket.

Why: Very few payers are reimbursing for 3D in the absence of severe problems that require meticulous viewing. And some payers will not approve 3D, a more expensive modality, when the suspected problem for which the ob-gyn performs it has no treatment but merely provides more information.

AUDIO: Melanie Witt schools you on the ins and outs of coloscopic billing.

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Reading 44373’s code descriptor is key to getting your G Tube claim right.

Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the tube. I cannot find a code for repositioning a G tube; how should I code this scenario?

Answer: Judging by your encounter description, the patient’s percutaneous jejunostomy tube (J tube) slipped and became a percutaneous gastrostomy tube (G tube). On the claim, report the following:

• 44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneousgastrostomy tube to a percutaneous jejunostomy tube) for the EGD;
• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …) for the E/M;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99231 to show that the E/M and tube fix were separate services; and
• 536.42 (Disorders of function of stomach; gastrostomy complications; mechanical complication of gastrostomy) appended to 44373 and 99231 to represent the patient’s condition.

Explanation: The descriptor for 44373 might be a bit misleading, but it mentions only “tube conversion.” The tube does not necessarily have to be new.

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