Ob-Gyn Coding Alert


How Past History Impacts Present Care and Coding

Past, family and/or social history (PFSH) is perhaps more relevant to ob/gyn than any other specialty. Patients with a personal history of sexually transmitted diseases (STDs) or miscarriage, family histories of gynecological cancer, etc., change how you approach diagnostic coding. Including the right diagnostic codes is critical to ensure that tests and procedures ordered are covered services.

History, examination and medical decision-making are the three pillars of E/M visits, and their documentation determines the level of E/M service that can be billed. But patient history is an easily overlooked portion of the patient record that cannot only drive the E/M level but also significantly impact patient care. And in the field of ob/gyn, questions about patient history are often more sensitive than in other fields, such as asking someone details about her sex life.

Patricia Horvatich, office manager for Robyn M. Cook, MD, a solo practitioner in Kealakekua, Hawaii, says that her practice uses a detailed questionnaire that asks very specific questions about patient history. "For example, rather than ask, 'What type of birth control do you use?'" Horvatich says, "we list every type of birth control, including 'withdrawal/rhythm method,' and the patient just has to circle her choice." She adds that over the years, the form has been revised for greater specificity to achieve the most accurate patient history.

Aspects of PFSH

Per CPT, past, family and/or social history is divided into three subsections.

1. Past history includes the patient's experience with illnesses, injuries and treatments, including:

  • prior major illnesses and injuries
  • prior operations
  • prior hospitalizations
  • current medications
  • allergies
  • age-appropriate immunization status
  • age-appropriate feeding/dietary status.

    2. Family history includes a review of health-related events in the patient's family, including:

  • health status or cause of death of parents, siblings and children
  • specific diseases related to problems identified in the chief complaint or history of the present illness, and/or system review

  • diseases of family members that may be hereditary or place the patient at risk.

    3. Social history covers past and current activities related to:

  • marital status and/or living arrangements
  • current employment
  • occupational history
  • use of drugs, alcohol and tobacco
  • level of education
  • sexual history
  • other relevant social factors.

    For the ob/gyn patient, family or personal history of disease, and personal sexual history are likely to have the biggest impact on coding and patient management.

    Personal History

    A 38-year-old woman reports to her ob/gyn with a positive pregnancy test. This is the third pregnancy for the patient, whose first two pregnancies ended in fetal death prior to 22 weeks. Because of the risk of miscarriage, the physician schedules monthly ultrasounds to evaluate fetal development and performs several biophysical profiles during the pregnancy when the patient complains of decreased fetal movement. The ob/gyn sees the patient a total of 20 times during the course of her pregnancy, which results in a normal live birth by vaginal delivery.

    The overall management of the pregnancy is billed as 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care), linked to 650 (Normal delivery) and V27.0 (Outcome of delivery; single liveborn) because the delivery was completely normal. The patient, however, was also at high risk due to her past history. Consequently, using V23.5 (Pregnancy with other poor reproductive history) and V23.82 (Elderly multigravida) informs the carrier that you will bill the tests and the additional visits.

    Because global ob care typically includes 13 antepartum visits, the practice should code the additional seven visits as E/M services (9921x, Office or other outpatient visit for the evaluation and management of an established patient ). These visits will be linked to codes V23.5 and V23.82, as will the charges for the ultrasounds, assuming no problems are found. The biophysical profiles will be linked to the ICD-9 code for the complaint of decreased fetal movement, 659.73 (Abnormality in fetal heart rate or rhythm; antepartum condition or complication).

    As soon as the global care is initiated, coders should alert the patient's carrier to her high-risk status, specifying that V23.5 is for history of neonatal death. This way, when the final global bill comes in with extra charges, the carrier in theory will not balk at paying for the additional office visits and services.

    Family History

    A 25-year-old new patient reports to her ob/gyn for her annual well-woman exam. Her patient information form, as well as discussion with the ob/gyn, reveals that her mother and older sister died of breast cancer. Although the usual age for mammogram screening is 35 and older, the ob/gyn recommends that the patient, who has never had a mammogram, have one annually starting immediately. The patient returns to the office a few days later when the mammogram technician is present and has a mammogram, which comes back negative. She is asked to perform frequent breast self-exams and, henceforth, her annual well-woman visit always includes a mammogram.

    Procedural coding for this patient is straightforward. The first well-woman visit is coded as 99385 (Initial comprehensive preventive medicine evaluation and management 18-39 years), and subsequent well-woman visits are coded 99395 (Periodic comprehensive preventive medicine re-evaluation and management 18-39 years). The ICD-9 code linked to the annual well-woman exam is V72.3 (Gynecological examination).

    The annual mammogram is coded 76092 (Screening mammography, bilateral [two view film study of each breast]), linked to V76.11 (Screening mammogram for high-risk patient) and V16.3 (Family history of malignant neoplasm; breast). The presence of the V76.11 and V16.3 codes on the claim form should quell any hesitance that the patient's carrier might have in paying the annual mammography claim for a patient of this age.

    Cindy Rodgers, CPC, reimbursement and compliance specialist with Kroeger-Miller and Associates LLC in Knoxville, Tenn., agrees that anytime there is a family history of cancer, the coding picture changes. "If the patient has a family history of ovarian cancer, for instance, the recommended protocol includes ordering a CA-125 (86304, Immunoassay for tumor antigen, quantitative; CA 125) and performing a pelvic ultrasound (76856,Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) annually in addition to her annual exam. You would support the additional diagnostics with V76.46 (Special screening for malignant neoplasms, ovary) and V16.41 (Family history of malignant neoplasm, ovary)," Rodgers says.

    Social History

    An 18-year-old woman reports to her gynecologist with a complaint of vaginal itching. Her patient history form indicates that she has genital herpes and has been treated for chlamydia. The interview with the physician indicates that she currently has more than one sexual partner and uses condoms sporadically. The physician completes the exam portion of the E/M visit and counsels the patient on the risk of sexually transmitted and blood-borne diseases, gives her a pamphlet on STDs, and renews her prescription for oral contraceptives. She orders blood work for HIV testing because this has not been done before, and a full STD panel. She schedules the patient to return for follow-up in three months for the vulvovaginitis, assuming the test results are normal.

    This problem-oriented visit is coded as 99214 (Office or other outpatient visit for the evaluation and management of an established patient ), linked to 616.10 (Vaginitis and vulvovaginitis, unspecified). The high level of E/M visit is due to the patient's risky behavior and the documented time spent counseling her.

    The collection of the blood sample for the lab work for the patient (36415*, Routine venipuncture or finger/heel/ear stick for collection of specimen[s]) and the reason for the lab tests will be linked to V69.2 (High-risk sexual behavior) and V13.8 (Personal history of other specified diseases). Although the blood test will be billed by the laboratory, the orders for testing should include the diagnostic reasons for the test.

    The patient, who is still insured under her parent's policy, normally would not be eligible for an HIV and other tests done routinely. But here the diagnostic reasons given for the tests justify the screening for STDs and other diseases related to patient behavior.

    Medicare and High Risk

    Medicare has specific definitions of what makes a patient high-risk regarding gynecological care. These risk factors take the CPT E/M guidelines a step further and elaborate on PFSH elements that might place a patient in a high-risk category, as follows:

  • onset of sexual activity under 16 years of age (V69.2, High-risk sexual behavior)
  • five or more sexual partners in a lifetime (V69.2)
  • history of sexually transmitted disease (V13.8)
  • absence of three negative Pap smears (795.0,Nonspecific abnormal Papanicolaou smear of cervix)
  • history of HIV (V08, Asymptomatic HIV infection status, or 042, HIV disease)
  • absence of any Pap smears within the previous seven years (V15.89, Other specified personal history presenting hazards to health; other)
  • prenatal exposure to DES (760.76, Noxious influences affecting fetus via placenta or breast milk; diethylstilbestrol [DES]).

    These risk categories determine how frequently Medicare will pay for a screening breast and pelvic exam (G0101 [Cervical or vaginal cancer screening; pelvic and clinical breast examination] and Q0091 [Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory]). If the patient is positive on one or more of the above risk factors, Medicare will cover her exam once every year. If these risk factors are not present, Medicare will pay for the testing once every two years.

    Updating PFSH

    Most PFSH information can be updated annually and may involve the physician reviewing the history chart when the patient reports for her well-woman visit. Other practices ask patients to update their own information. Horvatich says that at her practice, patients update their history forms annually. The practice has two forms, one for new and one for established patients. The established patient form is a medical history update and asks for only recent information about patient menstrual, gynecological and sexual history.