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Choose The Correct Icd-9, Icd-10 Code For Postmenopausal Abnormalities
Avoid your reimbursement denial by taking these postmenopausal abnormality scenario challenges.
Case 1: Your ob-gyn sees a post menopausal patient with an inflamed vagina because the tissues are thinning and shrinking. The ob-gyn notices decreased vaginal wall lubrication. This patient is experiencing vaginal soreness and itching, painful intercourse, and bleeding after intercourse. The ob-gyn diagnoses the patient with _________, and you should report this with _________.
Case 2: Your ob-gyn sees a post menopausal patient with unusual or abnormal vaginal bleeding. You should report _________.
Solution 1: The ob-gyn diagnoses the patient with atrophic vaginitis, and you should report this with 627.3 (Menopausal and postmenopausal disorders; postmenopausal atrophic vaginitis). Normally, the lack of estrogen during and following menopause causes this condition. Additional causes for atrophic vaginitis include decreased estrogen due to decreased ovarian function after radiation or chemotherapy, oophorectomy, postpartum changes and immune disorders.
The ob-gyn will diagnose this condition via a pelvic exam, which will reveal thin, pale vaginal walls, but he may order lab tests to confirm menopause and rule out other conditions that might resemble it. According to Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M., for potentially menopausal women who may have premature ovarian failure or who are being evaluated for risk of other health problems, the ob-gyn can order one or more of the following tests:
• follicle-stimulating hormone (FSH): to determine whether she is approaching or has gone through menopause
• estradiol: to measure ovarian production of estrogen and to evaluate whether the menstrual cycle is normal
• thyroid function testing (free T4 and TSH): to test the function of the thyroid gland, which can slow with age, affect menstruation, and cause some symptoms similar to those seen with menopause.
For this condition, your ob-gyn may prescribe topical estrogen creams or tablets for vaginal use or transdermal estrogen. Writing prescriptions is part of the office visit (99201-99215, Office or other outpatient visit …), Witt says.
Report with ICD-10: When ICD-10 goes into effect, you'll report N95.2 (Postmenopausal atrophic vaginitis) instead.
This Condition should be linked to Endometrial Biopsies
Solution 2: Your ob-gyn sees a post menopausal patient with unusual or abnormal vaginal bleeding. You should report 627.1 (Menopausal and postmenopausal disorders; postmenopausal bleeding). Endometrial atrophy (621.8) or endometrial or vaginal cancer can cause postmenopausal bleeding.
Remember: The patient may also be on hormone replacement therapy which can cause this bleeding, have atrophic vaginitis, have recently lost weight (which affects the body by releasing stored estrogen), or have fibroids or polyps.
For this condition, the ob-gyn may be required to perform biopsies of the endometrium (58100-58110 or 58558, Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C), D&C (58120, Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]), or hysteroscopy (58555, Hysteroscopy).
About the Author
Suzanne Leder, M.Phil., CPC, COBGC can answer your ob-gyn coding questions, as she has been the Ob-gyn Coding Alert editor for five years and counting. Also, she holds a specialty OB/GYN coding certification. Currently, she is an Executive Editor at the Coding Institute and has covered topics in cardiology, physical medicine and rehab, gastroenterology, neurology, neurosurgery, orthopedics, and otolaryngology. She has a BA from N.C. State University and an international Master's degree (M. Phil) from Trinity College Dublin.
Em End-Result Guides You On Which Icd Code To Go For Ob-Gyn Coding
Situation: A patient came for an initial OB visit. Some other clinic confirmed her pregnancy, but she has never received prenatal care. She received her usual initial OB service (i.e. lab orders), Pap smear, and chlamydia trachomatis (CT)/neisseria gonorrhoeae (GC) screening. After discussing some concerns with the patient, the ob-gyn ordered another pregnancy test, the outcome of which was negative. Then he ordered an ultrasound (US) which showed no intrauterine pregnancy. The ob-gyn noted bilateral polycystic ovaries, however. In short, the office completed the initial OB visit prior to knowledge of a negative pregnancy test (given the confirmation documentation of a positive pregnancy test). I'm not sure whether to bill it as an initial or an office visit. What code should I use for the first diagnosis?
Solution: The suggestion is to code what you know at the end of the visit. Since the patient was not pregnant, you should report an outpatient E/M visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …; 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient …). As it turned out, you weren't providing global OB care nor were you supervising a pregnancy after all.
Your final diagnosis should be 256.4 (Polycystic ovaries) with V72.41 (Pregnancy examination or test, negative result). According to the CPT Assistant, you would code the ultrasound as an OB ultrasound (76805-76815). Therefore, you should link the ultrasound to V72.41. Here's what the guideline states:
"For a patient with an established diagnosis of pregnancy (determined by any means), with signs and symptoms that could be pregnancy related and necessitating an ultrasound evaluation of the pelvis, the obstetrical ultrasound code(s) 76805-76815 should be reported, even if the outcome of the procedure is that the patient is now not pregnant or has an ultrasonic diagnosis that might be deduced as being independent of the pregnancy (e.g., acute appendicitis, torsed ovary, necrotic fibroid)."
Report with ICD-10: Your new ICD-10 system will list 256.4 as E28.2 (Polycystic ovarian syndrome). V72.41 will be replaced by Z32.02 (Encounter for pregnancy test, result negative).
About the Author
Suzanne Leder, M.Phil., CPC, COBGC can answer your ob-gyn coding questions, as she has been the Ob-gyn Coding Alert editor for five years and counting. Also, she holds a specialty OB/GYN coding certification. Currently, she is an Executive Editor at the Coding Institute and has covered topics in cardiology, physical medicine and rehab, gastroenterology, neurology, neurosurgery, orthopedics, and otolaryngology. She has a BA from N.C. State University and an international Master's degree (M. Phil) from Trinity College Dublin.
