Ob-Gyn Coding Alert

Here's what you should look for in your physician's documentation.

When ICD-9 becomes ICD-10 in 2013, you will not always have a simple one-to-one relationship between old codes and the new ones. Often, you'll have more options that may require tweaking the way your physician documents a service and a coder reports it.

Check out this common annual visit diagnosis, and discover what you'll report after October 1, 2013.

When a patient comes in for an annual exam, you should attach V72.31 (Routine gynecological examination) to an annual visit code (99384-99386 for new patients, or 99394-99396 for established patients).

ICD-10 difference: Instead of relying on one code, V72.31 will expand into two options. They are Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings) and Z01.419 (... without abnormal findings).

Physician documentation: The key difference between Z01.411 and Z01.419 is whether the visit revealed an abnormal finding during the examination of the patient. The ob-gyn must document this. For instance, the physician might examine the patient and note, "cervix is red with excoriated edges," which leads to the decision to perform a biopsy. Note: "Abnormal findings" does not refer to a Pap result or a test that went to pathology.

Coder tips: Instead of relying on V72.31 as your catch-all annual visit diagnosis, you'll need to examine your physician's documentation. In other words, you will be looking at the examination part of the visit and what the ob-gyn notes for the appearance of the external genitalia, vagina, uterus, and so on. If the ob-gyn does describe an abnormality, you'll report Z01.411. If not, you'll report Z01.419.

Remember, if your physician does document an abnormal finding, you'll most likely include that finding on your ICD-10 claim as well.

Superbill: Your suberbill should list both codes (usually on the back but sometimes on the front if your physician is using a gynecology form) with a check box.