Ob-Gyn Coding Alert

Question: We are having issues when Medicare is the primary insurer. They do not want to cover anything listed with a V22.1 dx code. Our physician normally does:

• prenatal panel (which they split up, and RPR and HIV is not allowed with V22.x dx code). Should we use V74.5 and V73.89?
• urine culture (which we have no dx code to send besides V22.x). They are not allowing that code.
• cbc/glucose screening codes.

What codes should we be using if not these?

Texas Subscriber

Answer: Medicare follows American Congress of Obstetricians and Gynecologists (ACOG) guidelines. Code V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy) would not be correct for most routine antepartum testing.

You should be using the V28.x (Antenatal screening) codes for this screening. You cannot use V74.5 (Screening examination for venereal disease) or V73.89 (Other specified viral diseases) as a primary diagnosis for a pregnant patient if the testing is done as part of antenatal testing. 

A UA for protein and glucose is always part of the global package, and while a urine culture would not be included, Medicare will never pay for a routine screening test unless it is one of their covered preventive services. So, for the culture, you will not get reimbursed most likely unless it is done for diagnostic reasons. A urine culture is recommended by ACOG as part of routine testing for the pregnant patient, so report a V28.x code would be appropriate here as well.

ICD-10: When your diagnosis code system changes, you'll have new options for those codes mentioned in this answer:

Code V22.0 expands into four options: Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester), Z34.01 (... first trimester), Z34.02 (... second trimester), Z34.03 (... third trimester).

Code V22.1 will include the four new codes listed above as well as four more: Z34.80 (Encounter for supervision of normal pregnancy, unspecified, unspecified trimester), Z34.81 (... first trimester), Z34.82 (... second trimester), and Z34.83 (... third trimester).

Codes in the V28.x category will become Z36 (Encounter for antenatal screening of mother). Notice that all of the V28.x codes are replaced by this single Z code.

Code V74.5 will become Z11.3 (Encounter for screening for infections with a predominately sexual mode of transmission).

Code V73.89 will become either Z11.59 (Encounter for screening of other viral diseases) or Z11.4 (Encounter for screening for human immunodeficiency virus [HIV]).