Ob-Gyn Coding Alert

Recently we have had patients come in with urinary incontinence and ask for nonsurgical intervention, says Tonia Shoulders, RN, of Midwest Ob-Gyn Association, St. Louis, MO. Our office plans to initiate a program of nonsurgical treatments but we need to be sure we can be reimbursed for the therapies and time involved.

Understanding the Problem

Female urinary incontinence is a condition with severe economic and psychosocial impact, and it is not just a geriatric problem. Its prevalence in healthy middle-aged women, according to a 1995 study published in Clinical Obstetrics and Gynecology, is as high as 30 percent and may be as high as 47 percent among women who exercise. The cause of urinary incontinence is usually attributed to three common types: stress (625.6), urge (788.31) or flow (788.34). These conditions, especially stress incontinence, may be associated with pelvic organ prolapse and pelvic floor defects as a result of gynecological surgery; vaginal births; underlying neurologic, gastrointestinal, or pulmonary disease; smoking; obesity; and occupational and recreational factors. In many cases these conditions are treated with surgery.

Patty Kulpa, MD, a sports gynecologist and urogynecologist from Gig Harbor, WA, states in an article in The Physician and Sports Medicine, that often, nonsurgical treatment is effective for urinary stress incontinence. Once an appropriate medical, gynecologic and urologic history is taken and a thorough examination is performed, the patient and physician may choose a course of treatment and management that does not include surgery. According to Shoulders, these nonsurgical treatments may include a variety of approaches, such as counseling, exercise teaching, use of mechanical devices, pharmacological agents, biofeedback programs and electrical stimulation. These treatments present a variety of challenges for the ob-gyn coder.

Counseling and Exercise and Biofeedback Training

One of the most common conservative treatments for incontinence is to educate the patient in pelvic floor rehabilitation through awareness and instruction in doing exercises. A common exercise known as Kegel exercises increases the muscle volume of the pelvic floor and develops stronger reflex contractions following a quick rise in intra-abdominal pressure (the precipitating factor in stress incontinence). However, many women lack an awareness of these muscles and do not know how to contract their pelvic floor muscles and perform the necessary exercises. According to Shoulders, more than a brief verbal explanation or educational pamphlet is needed to assist women in developing an exercise program. Along with exercise training, the patient is also instructed in the use of biofeedback techniques. Shoulders says that in many practices this counseling and training service will be provided by nurses.

If the nurse is providing incontinence counseling, it may be billed as a skilled nursing office visit, coded simply with the office visit codes 99211-99214, depending on the complexity of the patients presentation. A 99211, for example, is an office visit that does not require the presence of the physician and typically lasts only five minutes. Codes 99212-99214 would require a more detailed history, examination and decision-making, but if more than 50 percent of the face-to-face time was spent in counseling the patient, the E/M code would be selected based on time. Biofeedback can be billed using CPT code 90911 (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry). Remember, however, that many payers assume that the use of these codes means a physician provided the service. Therefore billing departments should always check with the payer about billing directly for nonphysician services. In order to be considered for payment, however, these office visits must meet three requirementsthey must clearly be for a problem, the counseling or instruction must be provided by an RN, and the payer must define an RN as an appropriate provider of the services.

Vaginal Cones

Often used in conjunction with exercise are small vaginal cones to aid in pelvic floor rehabilitation. These cones are a training aid specifically developed to assist women in identifying and exercising the pelvic floor muscles. A common problem clinicians see is the difficulty women have in identifying the correct muscle group when doing Kegel exercises. Vaginal cones are a set of graduated weights that are inserted and carried in the vagina for 15 minutes twice a day. The cones provide a powerful sensory feedback, which makes the pelvic floor contract around the cone and retain it. As the pelvic floor muscles are strengthened, the weight of the cones is gradually increased. Improved tone of this muscle group assists in reducing urinary leakage.

According to Shoulders, showing women how to use and clean the vaginal cones usually takes from 15 to 30 minutes and may involve additional counseling. Coding for instructing the woman how to use the vaginal cones is essentially an E/M service with the supply code 99070. The level of E/M service for teaching a patient about vaginal cones should never be higher than a level three encounter (99213). Staff will need to check with the payer to see if the cones are a covered benefit. These cones are not listed among the items that are covered by Medicare, so practices should prepare patients for the news that the service will be an out-of-pocket expense.

Electrical Stimulation

Another treatment is the electrical stimulation of the pelvic floor. This procedure involves stimulating the pelvic viscera, pelvic muscles or nerve supply to these structures. It improves continence by increasing urethral closure pressure. Coding for this service depends on who performs it. If the physician does the electrical stimulation, he or she can report one of two codes. The code 64550 is used for the placement of surface neurostimulators and for the placement of intravaginal stimulators, the code would be 64555. If the RN performs this service, the code is 97014 if there is not constant physician attendance or 97032 if there is.