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CASE STUDIES IN CODING
Practical advice on reimbursement
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In the June 2004 issue [pp 90-97], I discussed the coding guidelines for reporting multiple surgical procedures. There are also instances in which multiple ultrasounds (U/S) are performed, and they can occur on the same day or in the case of obstetrical U/S, during a single pregnancy. Let's look at the case of Desdemona, who has multiple U/S procedures during her pregnancy.
Desdemona, a 29-year-old G4P1-0-2-1, presents at 16 weeks to Dr. Cassio for an U/S to assess gestational age and fetal anatomy. Findings revealed fetal biometric parameters consistent with dates. There were no fetal malformations; however, the stomach was not visualized. She was scheduled for a follow-up U/S in 3 weeks.
At 19 weeks, Dr. Cassio performed a follow-up U/S. The stomach was visualized and appeared normal. Later that week, Desdemona was given findings from an abnormal triple screen and referred to Dr. Othello, a maternal-fetal medicine specialist who has substantial training in advanced U/S.
Dr. Othello performed a detailed fetal anatomic examination, which showed normal fetal anatomy. The patient opted against a genetic amniocentesis. The remainder of Desdemona's pregnancy was uncomplicated and she delivered a healthy 7 lb, 15 oz female at term.
Dr. Cassio's services. Dr. Cassio reported CPT code 76805 to describe the initial screening U/S (Figure 1). This code is specific for a transabdominal U/S performed after the first trimester and includes measurements and evaluation of fetal anatomy appropriate for the gestational age. Since the stomach was not fully visualized, another U/S was performed at 19 weeks. Code 76816 was reported for the subsequent U/S since it was done to follow up on a previously discovered condition (Figure 2). The CPT code descriptor for 76816 includes examples of possible uses including "re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan."
Dr. Cassio selected ICD-9 code V28.8 (other specified screening) for the initial U/S since it was part of routine screening services. ICD-9 code V28.3 (screening for malformations using ultrasonics) was reported for the second U/S to support the need for the follow-up service. If a definitive condition had been found, then Dr. Cassio would have reported the specific code for these findings.
Dr. Othello's services. Dr. Othello's service is provided in response to an abnormal triple screen, which supports the need for a detailed fetal anatomic examination (Figure 3). In addition to a detailed evaluation of the fetal anatomy, code 76811 includes all the components of the fetal and maternal evaluation incorporated in code 76805. The specific components are outlined in the introduction to the obstetrical U/S codes in CPT. Generally, this detailed fetal anatomic examination is reported only once per pregnancy.
Because Dr. Othello performed the detailed U/S in an outpatient hospital setting (place of service 22), modifier -26 is appended to the U/S code to indicate that only the professional interpretation and report are being submitted by him. The hospital will report the technical component (modifier TC) to reflect the use of its U/S equipment.
Dr. Othello reported ICD-9 code 796.5 (abnormal findings on antenatal screening) in addition to code V28.3. The additional diagnosis further explains the clinical rationale for performing a detailed fetal evaluation. Code V71.89 (observation for other specified conditions) can also be added to the claim. The V71 category of codes is used when services are provided to patients suspected of having a condition but who do not have a diagnosis, sign, or symptom. They are only used when the suspected condition is not found. If a condition is found, then the code that describes the finding is reported.
There are also situations when it is appropriate to report two U/S on the same day.
Consider Miranda and the services provided by Dr. Antonio (Figure 4).
Miranda, a 24-year-old G1P0, is 34 weeks by dates and has Type I diabetes mellitus. Her original U/S at 16 weeks was normal. At her prenatal visit today, the uterine fundus measures 40 cm on examination. An U/S is performed and polyhydramnios is diagnosed. Because of her diabetes and polyhydramnios, a biophysical profile is also performed.
Dr. Antonio submits codes 76816 (ultrasound pregnant uterus, follow-up) and 76818 (biophysical profile). A fetal and maternal evaluation, follow-up or limited U/S may be reported with a biophysical profile (BPP) when performed on the same day. These examinations are different. An U/S is an anatomic examination and a BPP is a physiologic examination measuring the well-being of the fetus. Code 76818 includes the performance of a non-stress test (NST). If an NST is not performed by the person interpreting the BPP, then code 76819 (BPP without NST) should be used. Likewise, the physician interpreting the NST would bill only for that service, using code 59025. The documentation must clearly indicate the clinical need and the interpretation for each test. The follow-up U/S code was reported since it is likely that a fetal and maternal evaluation was performed earlier in the pregnancy and this one was performed to reevaluate fetal size.
Note that in Figure 4 there are no modifiers. The U/S codes that appear in CPT represent both the technical and professional components of the service. Since the services were provided in Dr. Antonio's office, he reports the U/S code without a modifier to reflect his interpretation and the use of his U/S machine. The -51 modifier does not need to be appended when multiple U/S are performed on the same day.
Dr. Antonio associated the polyhydramnios (657.03) and the diabetes (648.03 and 250.01) diagnoses with the BPP to clearly indicate the reasons the additional study was performed. He elected to link only the diagnosis for "large for dates" (code 656.63) to the initial maternal-fetal U/S as a means to relate the sequence of services and clearly justify the need for both U/S. Since these conditions were noted in the antepartum period, the 5th digit 3 was used on the pregnancy-related diagnoses. When diabetes complicates the pregnancy, ICD-9 instructions specify that the type of diabetes should be reported in addition to the code specific to the pregnancy.
On occasion it may be necessary to perform both transvaginal and transabdominal U/S at the same encounter. CPT instructions state that both services can be reported. If that is the case, the documentation should support the medical necessity for both procedures and be clear in the patient's record. Some payers initially may pay for either the transvaginal or the transabdominal approach but not both. It may be helpful to attach the -59 modifier (Distinct Procedural Service) to the transvaginal code. It may also be necessary to send a cover letter with the claim that further explains the clinical need for both approaches.
September 10-12, 2004
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Ms. Hill is President of Hill & Associates, Inc., a consulting firm specializing in coding and compliance. She teaches coding seminars for the American College of Obstetricians and Gynecologists and serves as a representative on the American Medical Association's Correct Coding Policy Committee and the Health Care Professionals Advisory Committee Review Board for the Relative Value Update Committee (RUC) and the National Uniform Claim Committee. She has also served on the AMA's CPT-5 Project and on a Clinical Practice Expert Panel for the Centers for Medicare and Medicaid Services (formerly HCFA) Practice Expense Study.
Emily Hill. Case Studies in Coding: Coding for multiple ultrasounds. Contemporary Ob/Gyn Sep. 1, 2004;49:110-114.