416 Practice Matters · PDF file · 2016-12-06Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS ... They saw all OB triage and ED gynecology patients for their own

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SOGHNewsletter4.2016

“CODETHIS!”(CaseoftheMonth)MissedAbortion,RetainedPOCwithChorioamnionitistreatedwithD&C

byLori-LynneA.Webb,CPCandReneeAllen,MD,FACOGFebruary25,2016CaseExcerpt(summaryandnarrativeofactualcase):

A29yoG1P0at183/7weekspresentedtothehospitalforevaluationofdecreasedfetalmovementat0830.Thepatientreportedpersistentmucusdischarge,moderateleakageoffluid,andmildcontractionsovertheprevious2-3days.Abedsideultrasoundconfirmedanintrauterinepregnancyat18weeksgestationwitholigohydramniosandnofetalcardiacactivity.Thepatientwas3-4cmdilatedandhertemperaturewas100.7degreesFahrenheit.Shewasinformedofthefindings,providedwithsupport,andadmittedtotheOBGYNhospitalistservicewithdiagnosisofintrauterinefetaldemiseat18weeks'gestationandchorioamnionitis.

Misoprostolaugmentationoflaborwasstartedandanepiduralwasplaced.Gentamycinandclindamycinwereordered(thepatienthadapenicillinallergy).Thepatientprogressedwellandspontaneouslydeliveredamalefetusofapproximately17weeksgestationalage.Herplacentaalsodeliveredspontaneously.However,examinationoftheplacentarevealedaraggedappearance,soasecondbedsideultrasoundwasperformedwhichdiagnosedretainedproductsofconception.AttemptsatmanualevacuationoftheuteruswereunsuccessfulandthepatientwastransferredtotheL&DORwhereadilation&curettagewasperformed.Auterinecrywasnotedatthecompletionoftheprocedurewhichsuggestedasuccessfulevacuationoftheuterus.Evacuationwasconfirmedbyafinal,intraoperative,ultrasound.AllthreeultrasoundswereperformedbytheObhospitalistcaringforthepatient.

IfyouweretheObhospitalistinthiscase,howwouldyoucodeandbillyourservices?

ANSWER:

DiagnosisCodes(ICD-10):O02.1 MissedabortionO41.1220 Chorioamnionitis,secondtrimester,notapplicableorunspecifiedZ3A.18 18weeksgestationofpregnancyE&M Item Modifier99223-25 AdmissionH&P 25=E&MandProcedure CPT Item Modifier


76815 Ultrasound,OBLimited 26=ProfessionalComponent

59830 TreatmentofSepticAbortion,completedsurgically

76998-26 Ultrasound,Intraoperative 26=ProfessionalComponent

CodingBrief:Whilethediagnosesdocumentedinthepatient’schartisnotedasIUFDat18weekswithchorioamnionitis,whichiscommonvernacularforpracticingobstetricians,thisisnotconsistentwiththeICD-10billingdefinitions.Theencountermustbebilledunderadiagnosisofmissedabortionandchorioamnionitis.Thesearebothconsideredpregnancycomplications.

MissedabortioniscodedunderICD-10as002.1.Thebillingdefinitionformissedabortionis“earlyfetaldeath,beforecompletionof20weeksofgestation,withretentionofdeadfetus.”ChorioamnionitisiscodedasO41.1220anditsbillingdefinitionis“asingletongestationwithchorioamnionitisoccurringinthesecondtrimesterofpregnancy.”Thesecondtrimesterisdefinedas“betweenequaltoorgreaterthan14weeks,andlessthan28weekssincethefirstdayofthelastmenstrualperiod.”UnderICD-10,anypregnancycomplicationdiagnosiscodemustbeaccompaniedbyacodeintheZ3Afamily,whichspecifiesthegestationalage.InthiscaseZ3A.18denotes18weeksgestation.

Oncethediagnosiscodesarechosen,thenanappropriatelevelE&Mmustbeestablishedtobillthehistoryandphysical.AnyappropriateCPTcodesshouldalsobeaddedtobillprocedures.

ThedetailsofthiscaseeasilysupportusingtheE&Mcode99223.The99233diagnosiscodemaybebasedeitheronadirectdocumentationoftimespentonpatientcareoronthoroughdocumentationofacomprehensivehistory,physicalexam,anddecision-makingwithplanofcare.Thetimerequirementdocumentationforthe99223diagnosiscodeis“70minuteswerespentonthispatient'scare,ofwhichmorethan50%wasspentface-to-face,counselingheronthepregnancyprognosisandtreatmentoptions.”A25modifiermaybeusedinthiscasetoindicatethattheE&Mwasaseparatebutsignificantpartofthepatient'scarethatday.ThisisnecessarybecausemostCPTcodesincludepaymentforaroutinepreoperativeH&P.However,whenapatient'scareiscomplicatedbothanE&MvisitandaCPTprocedurecodecanbebilledonthesameday.

AlsoimportanttonoteisthattheD&CisnotcodedseparatelyinthiscasebutisincludedintheCPTcode59830,whichisthesurgicaltreatmentofsepticabortion.Ifthepatientdoes


notrequireaD&Ctoremovetheretainedproductsofconceptionoranyothersurgicalintervention,thiswouldprecludetheuseofthe59830CPTcode.

Finally,theCPTcodeforeachultrasoundcanbesubmittedandbilledseparately.Billinganultrasounddoesrequirethateachultrasoundbedocumentedinaseparatereport.Inaddition,imagesmustbesavedaspartofthepatient’smedicalrecord.Assumingtheuseofanultrasoundmachineownedbythehospital,youmaybillfortheprofessionalcomponentonlyandnotthetechnicalcomponentorfacilityfee.Lori-LynneA.Webb,CPC,CCS-P,CCP,CHDA,COBGCandICD10CM/PCSAmbassador/TrainerisanE&M,andProcedurebasedCoding,Compliance,DataChargeentryandHIPAAPrivacyspecialist,withover20yearsofexperience.Lori-Lynne’scodingspecialtyisOB/GYNoffice&HospitalistServices,MaternalFetalMedicine,OB/GYNOncology,Urology,andgeneralsurgicalcoding.Shecanbereachedviae-mailatwebbservices.lori@gmail.comoryoucanalsofindcurrentcodinginformationonherblogsite:http://lori-lynnescodingcoachblog.blogspot.com/.Dr.RenéeAllenservedasco-authorofthiscolumn.SheistheSOGHLiaisontotheACOGCommitteeonHealthEconomicsandCoding.ShecurrentlyworksasanOB/GYNHospitalistwithMednax/ObstetrixatEastsideMedicalCenterinSnellville,Georgia.

Questionsregardingthiscase?Contactusatcoding@societyofobgynhospitalists.org.

SOGH Newsletter 4.2016

PracticeMattersbyJoanneRichards,MDFebruary19,2016OBHospitalistprogramsarearelativelynewdivisionofOB/GYN,evolvingasthenumberofprogramsincreaseduetoincreasingdemands.Hospitalsindifferentcommunitieshavedifferingneeds,callingforflexibilityinwhatdefinestheroleofanOb/Gynhospitalistineachprogram.Ourprogram,theObstetrixOBHospitalistGroupatGoodSamaritanHospitalinSanJose,CAismeshedwiththeMednax(formerlyObstetrix)MFMgroupinSanJose.BoththeOb/Gynhospitalists,andtheperinatologists(MFM)areemployedbyMednax.OurOBGYNhospitalistprogramisalsopartiallyfundedbyGoodSamaritanHospital.Unlikeotherhospitalistemployers,Mednaxisanationalmedicalgroupcomprisedofneonatal,anesthesia,perinatologyandpediatricphysiciansaswellasOBHospitalists.Benefitsandcompensationarecorporatebased,butourprogramisuniquetotheSanJoseMFMgroup.TheSanJose,CAOb/GynHospitalistgroupbeganinJanuary2007atGoodSamaritanHospital.ItwasdesignedbyDr.AlanFishman,clinicaldirectoroftheSanJoseMFMgroup.Priorto2007,ourprivatephysicianshandledallthepatientsintheirowncallgroups.TheysawallOBtriageandEDgynecologypatientsfortheirowngroupsaswellastakingarotationalcallforunassignedpatientsbothintheEDandL&D.Otherobstetriciansorregisterednursefirstassistants(RNFA)providedsurgicalassistance.Beforeitwasrolledout,Dr.FishmanmetwiththecommunityOb/Gynphysicianstodiscusshowthenewprogramwouldinterfacewiththeircurrentpracticesandhowtheuseofhospitalistscouldbenefitbothphysiciansandpatients.TheOb/GynhospitalistsattendedaneighthourorientationwiththeperinatologistsandMednaxcorporateofficewhichdetailedpatientmanagement,billing,call,andthegeneraloperationaldetailsoftheprogram.TheprogrambeganinJanuary,2007andhassinceexpandedtoencompassourcurrentresponsibilities.Weareagroupoffourfulltimeandtwoparttimeemployeesworkingwithfiveperinatologists.GoodSamaritanHospitalperforms300-400deliveriespermonth.Wehave14laborroomsand3laboranddeliveryoperatingrooms.Thereis24hourdedicatedOBanesthesiaontheflooraswell.TheOb/Gynhospitalistsprovide24hr/7daycoveragein24hrshifts.Weprovideobstetricservicesforpatientswhodonothaveaprovideronstaff,coverageforanystaffobstetricianwhorequestsourservices,includingassistanceinC-sections,andweprovideemergencygynecologicalservicestotheunassignedgynpatients.Wealsoperformin-hospitalgynconsultsforpatientswithnostaffproviderandmakeappropriatereferralsforoutpatientfollowup.Inaddition,wearethefirstrespondersforallobstetricsandgynecologicalemergencies,includinganyunattendeddeliveries.OurgroupperformstriageevaluationforalltheperinatalpatientspresentingtotheObstetricsEmergencyDepartment(OBED)aswellasforpatientsoftheprivatepracticesuponrequest.AllOBEDpatientsarerequiredtobeseenbyaphysicianpriortodischarge,exceptthosepresentingforlaborevaluations.Wehavenooutpatientresponsibilities,soallpatientsarereferredforappropriatefollow-uppriortotheir







ANSWER:















SOGH Newsletter 4.2016

discharge.Patientsmayreturntotheirownphysician,theMFMclinic(fortheperinatalpatients)orarereferredtoanotherphysicianorclinic.AspartoftheMFMteam,wehelptoadmitandstabilizehelicopterandambulancetransferstotheMFMservice.WeattendthedeliveryforthemajorityoftheMFMpatientsandperformdailyroundswiththeperinatologistonalltheirpatients.WealsoperformemergencygynsurgeryandsomescheduledD&Cfortheperinatologyservice.Wearepartoftheperinatologyteamandtheperinatolgistsprovideuswitharoundtheclockbackup.Ifweareoverextendedorifweencounteranysituationwe’renotcomfortablemanaging,theperinatologistprovidesassistance.WeoftenworkcloselywithMFMasmanyofourpatientshaveacuteand/orcomplicatedconditions.Asignificantbenefitofourcloseworkingrelationshipwiththeperinatologistsisbeingconstantlyeducatedoncurrentstandardsofpracticeforbothhighriskandnormalpregnancies.Itisanexcitingandintellectuallystimulatingpracticeenvironment.Sincetheprogram’sinception,therehasbeenlittleturnoverinemployees.Assuch,thehospitalistsareatightlyknitgroup.Wenotonlyworktogetherasateamofprofessionals,weworktogetherasfriends.Wesupporteachotherwhenpersonalcrisesarise;whichmakesforanincrediblycohesivegroup.Ourgroupisdedicatedtoprovidingthebestcarepossible.Werunaveryconscientiousservicethatisstaffedbyverytalentedphysicians.Wealsoshareacloserelationshipwiththeperinatologists,andhaveacooperativerelationship,notasubservientone.Ourgrouphaveelectedtobepaidhourlyandsoincentivecompensationdoesn'tapply.Ourfulltimeemployeesreceiveemployeebenefits,includingacontinuingeducationstipend.OurmalpracticecoverageispaidbyMednax.Sincewereceivehourlycompensation,wedonothavepaidtimeoff(PTO)orvacationpay.Ourprogramhasalreadyweatherednineyearssuccessfullyandcontinuestoevolve.Theprivatephysiciansutilizeourservicesregularlyforcoverage,OBEDevaluationsandsurgeryassists.Theyareverypleasedwiththeprogram,asarethenursingstaffandhospitaladministration.Wearecontinuouslysupportedandeducatedbytheperinatologistswithwhomwework,andhaveagreatrelationshipasahospitalistgroup.WehaveabusyL&DunitandMFM/antepartumservice;aswellasacceptingtransportsfromotherhospitals,sothejobhasafairamountofstress.Butattheendoftheshiftyoucanwalkawayknowingthatyou'vehelpedimprovethequalityofcareandsafetyofthepatientswe’veserved.







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Documents

416 Practice Matters · PDF file · 2016-12-06Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS ... They saw all OB triage and ED gynecology patients for their own