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Coding Companion for
OB/GYN
A comprehensive illustrated guide to coding and reimbursement
2016
Contents
Getting Started with Coding Companion .............................i
Skin .....................................................................................1
Pilonidal Cyst.....................................................................11
Implant..............................................................................12
Repair ................................................................................15
Destruction........................................................................23
Breast ................................................................................24
Arteries and Veins ..............................................................40
Lymph Nodes ....................................................................43
Intestines ...........................................................................48
Anus ..................................................................................49
Abdomen ..........................................................................60
Ureter ................................................................................79
Bladder..............................................................................80
Urethra ..............................................................................93
Reproductive ...................................................................102
Vulva ...............................................................................103
CPT © 2015 American Medical Association. All Rights Reserved.
Coding Companion for OB/GYN
Vagina .............................................................................122
Cervix Uteri .....................................................................171
Corpus Uteri ....................................................................188
Oviduct ...........................................................................240
Ovary ..............................................................................256
In Vitro ............................................................................272
Maternity Care ................................................................275
Nervous...........................................................................328
Operating Microscope.....................................................332
Radiology ........................................................................333
Medicine .........................................................................346
HCPCS ............................................................................348
Appendix.........................................................................353
Correct Coding Initiative Update 20.3 .............................422
Evaluation and Management ...........................................475
Index...............................................................................497
© 2015 Optum360, LLC
Contents
58960
58960 Laparotomy, for staging or restaging of ovarian, tubal, or primary
peritoneal malignancy (second look), with or without omentectomy,
peritoneal washing, biopsy of abdominal and pelvic peritoneum,
diaphragmatic assessment with pelvic and limited para-aortic
lymphadenectomy
236.2
V10.43
V84.02
V84.04
HCPCS Equivalent Codes
N/A
Terms To Know
malignant. Any condition tending to progress toward death, specifically an
invasive tumor with a loss of cellular differentiation that has the ability to
spread or metastasize to other areas in the body.
Explanation
This procedure is the second operation to check for a recurrence of the ovarian
malignancy. Through a full abdominal incision extending from just above the
pubic hairline to the rib cage, the physician may elect to remove the omentum,
a membrane of lymph, blood vessels, and fat that forms a protective layer that
extends from the stomach to the transverse colon. The physician may flush
the lining of the abdominal cavity (peritoneum) and remove the liquid to
check for cancerous cells. A tissue sample of the abdominal and pelvic
peritoneum may be taken. The physician also may examine and take tissue
samples of the diaphragm. The pelvic lymph nodes are removed and a portion
of the lymph nodes that surrounds the lower aorta within the pelvis is removed.
The abdominal incision is closed with layered sutures.
omentum. Fold of peritoneal tissue suspended between the stomach and
neighboring visceral organs of the abdominal cavity.
peritoneum. Strong, continuous membrane that forms the lining of the
abdominal and pelvic cavity. The parietal peritoneum, or outer layer, is attached
to the abdominopelvic walls and the visceral peritoneum, or inner layer,
surrounds the organs inside the abdominal cavity.
Medicare Edits
58960
Fac RVU
Non-Fac RVU
FUD
Status
MUE
27.86
27.86
90
A
1(2)
Coding Tips
A prior surgery for ovarian malignancy should be documented. For initial
treatment and guidelines, see 58950–58952.
ICD-9-CM Diagnostic
183.0
183.8
196.6
197.6
198.6
198.89
209.71
209.74
209.79
Modifiers
58960
51
N/A
* with documentation
62*
Medicare Reference
80
None
Malignant neoplasm of ovary — (Use additional code to identify
any functional activity)
Malignant neoplasm of other specified sites of uterine adnexa
Secondary and unspecified malignant neoplasm of intrapelvic lymph
nodes
Secondary malignant neoplasm of retroperitoneum and peritoneum
Secondary malignant neoplasm of ovary
Secondary malignant neoplasm of other specified sites
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of peritoneum
Secondary neuroendocrine tumor of other sites
CPT © 2015 American Medical Association. All Rights Reserved.
Coding Companion for Ob/Gyn
© 2015 Optum360, LLC
Ovary — 271
Ovary
V84.09
Neoplasm of uncertain behavior of ovary — (Use additional code
to identify any functional activity)
Personal history of malignant neoplasm of ovary
Genetic susceptibility to malignant neoplasm of ovary — (Use
additional code, if applicable, for any associated family history of
the disease: V16-V19. Code first, if applicable, any current malignant
neoplasms: 140.0-195.8, 200.0-208.9, 230.0-234.9. Use additional
code, if applicable, for any personal history of malignant neoplasm:
V10.0-V10.9)
Genetic susceptibility to malignant neoplasm of endometrium —
(Use additional code, if applicable, for any associated family history
of the disease: V16-V19. Code first, if applicable, any current
malignant neoplasms: 140.0-195.8, 200.0-208.9, 230.0-234.9. Use
additional code, if applicable, for any personal history of malignant
neoplasm: V10.0-V10.9)
Genetic susceptibility to other malignant neoplasm — (Use
additional code, if applicable, for any associated family history of
the disease: V16-V19. Code first, if applicable, any current malignant
neoplasms: 140.0-195.8, 200.0-208.9, 230.0-234.9. Use additional
code, if applicable, for any personal history of malignant neoplasm:
V10.0-V10.9)
G0124
collected in preservative fluid, automated thin layer preparation,
requiring interpretation by physician
Explanation
These cervical or vaginal cytopathology screenings (any reporting system) of
specimens collected in preservative fluid may be identified as "thin prep." The
specimen is collected by cervical, endocervical, or vaginal scrapings or by
aspiration of vaginal fluid and cells. This method saves time by eliminating the
need for the physician to prepare a smear; the specimen is placed in a
preservative suspension instead. At the laboratory, special instruments take the
cells in the preservative suspension and "plate-out" a monolayer for screening,
which will carefully review the specimen for abnormal cells.
G0141
G0141 Screening cytopathology smears, cervical or vaginal, performed by
automated system, with manual rescreening, requiring interpretation
by physician
Explanation
This cervical or vaginal cytopathology screening is done on specimens prepared
in a smear. The specimen is collected by cervical, endocervical, or vaginal
scrapings or by aspiration of vaginal fluid and cells. The screening method is
microscopy examination of a spray or liquid fixated smear prepared by the
physician collecting the specimen. Screening, defined as the careful review of
the specimen for abnormal cells, may then be accomplished by different methods
that involve the use of automated systems.
G0425-G0427
G0425 Telehealth consultation, emergency department or initial inpatient,
typically 30 minutes communicating with the patient via telehealth
G0426 Telehealth consultation, emergency department or initial inpatient,
typically 50 minutes communicating with the patient via telehealth
G0427 Telehealth consultation, emergency department or initial inpatient,
typically 70 minutes or more communicating with the patient via
telehealth
Explanation
These codes are used to report an initial inpatient or emergency department
consultative visit or consultations that are furnished via telehealth in response
to a request by the attending physician. Telehealth is the delivery of
health-related services via telecommunications equipment. These services include
counseling and coordination of patient care with the other providers.
G0438-G0439
G0438 Annual wellness visit; includes a personalized prevention plan of service
(PPS), initial visit
G0439 Annual wellness visit, includes a personalized prevention plan of service
(PPS), subsequent visit
Explanation
The initial annual wellness visit (AWV) includes taking the patient’s history;
compiling a list of the patient’s current providers; taking the patient’s vital signs,
including height and weight; reviewing the patient’s risk factor for depression;
identifying any cognitive impairment; reviewing the patient’s functional ability
and level of safety (based on observation or screening questions); setting up a
CPT © 201 American Medical Association. All Rights Reserved.
Coding Companion for Ob/Gyn
G0444
G0444 Annual depression screening, 15 minutes
Explanation
Annual depression screening services are used to identify depression in patients.
There should be staff in place to ensure accurate diagnosis, effective treatment,
follow-up, and coordinate referrals. There are various tools that can be used to
determine the screening. Depression screening services do not include treatment
options for depression or any diseases, complications, or chronic conditions that
the patient may have due to the depression. It also doesn’t include any
therapeutic interventions, such as medication therapy, or a combination of drug
and counseling to treat the depression.
G0447
G0447 Face-to-face behavioral counseling for obesity, 15 minutes
Explanation
Behavioral counseling for obesity is reported with this code. The United States
Preventive Services Task Force (USPSTF) considers body mass index (BMI) a
good indication of morbidity and mortality as a result of being overweight or
obesity. BMI is calculated using the following formula: BMI = (weight in pounds
/ (height in inches x height in inches)) x 703. Obese adults are considered those
that have a BMI >=30 kg/m2. Behavioral counseling and behavior modification
can be an effective combination to produce moderate, sustainable weight loss.
The patients should have the following services: screening for obesity using BMI,
assessment of food and nutritional intake, and counseling to include diet and
exercise. Behavioral counseling interventions should include the following Five
A’s approach that has been developed by the United States Preventive Services
Task Force (USPSTF): Assess: Ask about/assess behavioral health risk(s) and factors
affecting choice of behavior and change goals/methods; Advise: Give clear,
specific, and personalized behavior change advice, including information about
personal health harms and benefits; Agree: collaboratively select appropriate
treatment goals and methods based on the patient’s interest in and willingness
to change the behavior; Assist: Using behavior change techniques (self-help
and/or counseling), aid the patient in achieving agreed-upon goals by acquiring
the skills, confidence, and social/environmental supports for behavior change,
supplemented with adjunctive medical treatments when appropriate; Arrange:
Schedule follow-up contacts (in person or by telephone) to provide ongoing
assistance/support and to adjust the treatment plan as needed, including referral
to more intensive or specialized treatment.
P3001
P3001 Screening Papanicolaou smear, cervical or vaginal, up to 3 smears,
requiring interpretation by physician
Explanation
A screening Papanicolaou (commonly referred to as Pap) smear, cervical or
vaginal, is a microscopic examination of cells scraped from the cervix or vaginal
wall. The smears are examined for any cells that appear to be abnormal. It is a
screening procedure when no known disease process exists.
© 201 Optum360, LLC
Appendix — 353
Appendix
G0124 Screening cytopathology, cervical or vaginal (any reporting system),
written patient screening schedule; compiling a list of risk factors, and furnishing
personalized health services and referrals, as necessary. Subsequent annual
wellness visits (AWV) include updating the patient’s medical and family history,
updating the current provider list, obtaining the patient’s vital signs and weight,
identifying cognitive impairment, updating the screening schedule, updating
the risk factors list, and providing personalized health advice to the patient.
Evaluation and Management
Although some of the most commonly used codes by physicians of
all specialties, the E/M service codes are among the least
understood. These codes, introduced in the 1992 CPT® manual,
were designed to increase accuracy and consistency of use in the
reporting of levels of non-procedural encounters. This was
accomplished by defining the E/M codes based on the degree that
certain common elements are addressed or performed and reflected
in the medical documentation.
The Office of the Inspector General (OIG) Work Plan for physicians
consistently lists these codes as an area of continued investigative
review. This is primarily because Medicare payments for these
services total approximately $33.5 billion per year and are
responsible for close to half of Medicare payments for physician
services.
The levels of E/M services define the wide variations in skill, effort,
and time and are required for preventing and/or diagnosing and
treating illness or injury, and promoting optimal health. These codes
are intended to represent physician work, and because much of this
work involves the amount of training, experience, expertise, and
knowledge that a provider may bring to bear on a given patient
presentation, the true indications of the level of this work may be
difficult to recognize without some explanation.
At first glance, selecting an E/M code may appear to be difficult, but
the system of coding clinical visits may be mastered once the
requirements for code selection are learned and used.
Providers
The AMA advises coders that while a particular service or procedure
may be assigned to a specific section, the service or procedure itself
is not limited to use only by that specialty group (see paragraphs 2
and 3 under “Instructions for Use of the CPT Codebook” on page xii
of the CPT Book). Additionally, the procedures and services listed
throughout the book are for use by any qualified physician or other
qualified health care professional or entity (e.g., hospitals,
laboratories, or home health agencies).
The use of the phrase “physician or other qualified health care
professional” (OQHCP) was adopted to identify a health care
provider other than a physician. This type of provider is further
described in CPT as an individual “qualified by education, training,
licensure/regulation (when applicable), and facility privileging
(when applicable).” State licensure guidelines determine the scope
of practice and a qualified health care professional must practice
CPT © 2015 American Medical Association. All Rights Reserved.
Coding Companion for OB/GYN
within these guidelines, even if more restrictive than the CPT
guidelines. The qualified health care professional may report services
independently or under incident-to guidelines. The professionals
within this definition are separate from “clinical staff" and are able to
practice independently. CPT defines clinical staff as “a person who
works under the supervision of a physician or other qualified health
care professional and who is allowed, by law, regulation, and facility
policy to perform or assist in the performance of a specified
professional service, but who does not individually report that
professional service.” Keep in mind that there may be other policies
or guidance that can affect who may report a specific service.
Types of E/M Services
When approaching E/M, the first choice that a provider must make
is what type of code to use. The following tables outline the E/M
codes for different levels of care for:
• Office or other outpatient services—new patient
• Office or other outpatient services—established patient
• Hospital observation services—initial care, subsequent, and
discharge
• Hospital inpatient services—initial care, subsequent, and
discharge
• Observation or inpatient care (including admission and discharge
services)
• Consultations—office or other outpatient
• Consultations—inpatient
The specifics of the code components that determine code selection
are listed in the table and discussed in the next section. Before a
level of service is decided upon, the correct type of service is
identified.
Office or other outpatient services are E/M services provided in the
physician or other qualified health care provider’s office, the
outpatient area, or other ambulatory facility. Until the patient is
admitted to a health care facility, he/she is considered to be an
outpatient.
A new patient is a patient who has not received any face-to-face
professional services from the physician or other qualified health
care provider within the past three years. An established patient is a
patient who has received face-to-face professional services from the
physician or other qualified health care provider within the past
three years. In the case of group practices, if a physician or other
qualified health care provider of the exact same specialty or
subspecialty has seen the patient within three years, the patient is
considered established.
If a physician or other qualified health care provider is on call or
covering for another physician or other qualified health care
provider, the patient’s encounter is classified as it would have been
by the physician or other qualified health care provider who is not
available. Thus, a locum tenens physician or other qualified health
care provider who sees a patient on behalf of the patient’s attending
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Evaluation and Management — 475
Evaluation and Management
This section provides an overview of evaluation and management
(E/M) services, tables that identify the documentation elements
associated with each code, and the federal documentation
guidelines with emphasis on the 1997 exam guidelines. This set of
guidelines represent the most complete discussion of the elements
of the currently accepted versions. The 1997 version identifies both
general multi-system physical examinations and single-system
examinations, but providers may also use the original 1995 version
of the E/M guidelines; both are currently supported by the Centers
for Medicare and Medicaid Services (CMS) for audit purposes.