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help with code a round obgyn

  1. Angry help with code a round obgyn
    Medical Coding Books

    CPT 11980
    CPT 99396 25
    ICD9 v72.31
    ICD9 627.4
    ICD9 256.31

    This is what has been accepted, but they still say I am missing one or more codes. Does anyone besides myself find these things more than chalenging? Here is the note:

    Chief Complaint: Annual exam

    Pt here for her annual exam, would like to have Pellets Implanted.

    History Of Present Illness:
    This patient requests hormone pellet insert. Indications reviewed and concems about ability to achieve physiologic levels, avoid peaks and troughs, and safety concerns such as bothersome side effects of testosterone have been reviewed.
    In this case the concern is of premature surgical menopause and inability to achieve adequate response from more standard forms of hormone therapy.
    The skin was prepped with betadine and 5 cc of xylocaine placed on anterior abdominal wall. Small nick in skin made with scalpel, the skin gently undermined. Subcutaneous pellet(s) were then inserted into the skin.
    Gentle pressure and a bandaid were applied and patient Instructed to keep the area dean and dry, to apply direct pressure if any bleeding occurs. To call if any concerns.
    The patient is a 44 year old female gravida para.
    Her general health issues include Ovarian Cancer.
    Social history reviewed. Has had marital counseling recently; husband getting testosterone injections. Very stressed about marriage, finances, spouse with health Issues he's not addressing and they run an autodealership so economy has hit very hard

    Past Surgical History: Abdominal hysterectomy with bilateral oopherectomy.

    Medication List
    Estradiol 50 mg pellet
    Spironolactone Oral Tablet 100 mg Testosterone 100 mg pellet
    Valtrex Oral Tablet 1 g
    Wellbutrin SR Oral Tablet Sustained Release 100 mg

    Revievtf of Systems:
    Constitutional - Denies : body aches, night sweats
    HENT - Denies : headaches, dental problems, neck stiffness, oral ulcers
    Breasts - Denies : lumps, tenderness, swelling, nipple discharge, abnormal changes In breast size
    Cardiovascular - Denies : chest pain, syncope, dyspnea on exertion, lower extremity edema, varicosities
    Respiratory - Denies : shortness of breath, cough
    Gastrointestinal - Denies : nausea, vomiting, diarrhea, constipation, abdominal pain, blood In stools, excessive flatulence
    Genitourinary - Denies : urgency, frequency, dysuria, hematuria. Incontinence, decreased libido, dyspareunia, genital sores. Irregular menses, menorrhagia, metrorrhagia, vaginal discharge, significant PMS.
    Integumentary - Denies : rash, changes to existing skin lesions or moles, hirsutism, Thinning hair-alopecia. Bothersome facial hair - age appropriate
    Neurologic - Denies : muscular weakness. Incoordination, tingling or numbness, difficulty concentrating, snoring
    Musculoskeletal - Denies : joint pain, joint swelling, muscle pain, muscle cramps, back pain
    Endocrine - Denies : polyuria, polydipsia, cold intolerance, heat intolerance, central obesity
    Psycliiatric - Denies : anxiety, depression, feeling confused, difficulty sleeping
    Heme-Lymph - Denies : easy bleeding, easy bruising, lymph node enlargement or tenderness
    Allergic-Immunologic - Admits : seasonal allergies

    Vitals:
    BMI is 24.14 kg/m2 .
    BP 100/70 WT 178 lbs 0oz HT 6' 0"

    Physical Examination
    Constitutional - Appearance : well-nourished, well developed, alert, in no acute distress
    Eyes - Conjunctiva/Eyelids : Normal appearance. Sclera : Normal appearacne.

    HENT- Head and Face : Pleasant, symmetrical, normal fades. No hirsutism. Ears : Extemal ears within normal limits. Hearing grossly Intact.
    Neck - Inspection/Palpation : normal appearance, no masses or tenderness. Thyroid : gland size normal, nontender, no nodules or masses present on palpation
    Chest - Respiratory Effort: breathing unlabored.
    Breasts - Inspection of Breasts : breasts symmetrical, no skin changes, no discharge present, no skin retraction present. Palpation of Breasts and Axillae : no masses present on palpation, no breast tenderness. Axillary Lymph Nodes: no lymphadenopathy present
    Gastrointestinal - Abdominal Examination : abdomen nontender to palpation, tone normal without rigidity or guarding, no masses present, umbilicus without lesions well healed scar from surgery. Liver and spleen : no hepatomegaly present, liver nontender to palpation. Hernias : no hernias present
    Genitourinary - External Genitalia : normal appearance for age, no discharge present, no tenderness present, no inflammatory lesions present. Vagina: normal vaginal vault without central or paravaginal defects, no discharge present, no inflammatory lesions present, no masses present. Bladder : nontender to palpation. Cervix: Absent. Uterus: Absent. Adnexa : no adnexal tenderness present, no adnexal masses present No nodularity. Perineum : perineum within normal limits, no evidence of trauma, no rashes or skin lesions present. Anus: anus within normal limits, Rectal: normal sphincter tone, no rectal masses present. Stool/Hemoccult Testing: Office testing not recommended-ACS guidelines normally followed.
    Lymphatic - Lymph Nodes : no other lymphadenopathy present
    Musculoskeletal - Lumbosacral Spine : No visible defects or deformities. Pelvis : No visible defects or deformities. Right.Upper Extremity: Inspection/Palpation: Appears normal. Motor Function: Appears normal. Left Upper Extremity: Inspection/Palpation: Appears normal. Digits and Nails: Appear normal. Range of Motion: Appears normal. Motor Function: Appears normal. Right Lower Extremity: Inspection/Palpation: Appears normal.Range of Motion: Appears normal Left Lower Extremity: Range of Motion : Appears normal
    Skin - General Inspection : no rashes present, no lesions present, no areas of discoloration.
    Scalp : no rashes present, no lesions present, normal hair pattern present Body Hair: general body hair distribution normal female for age. Pubic Hair: Normal for age
    Neurologic/ Psychiatric - Mental Status : altert, pleasant, and articulate. Coordination: coordination normal. Gait and Station : normal gait and station
    Assessment: Premature menopause. Premature Ovarian Failure/Menopause. Annual/Gynecological Exam Routine. Herpes Simplex, prior workup revealed type I genital lesions. Gets occasionally, had called for valtrex script.
    Plan:
    Orders: Mammogram, screening bilateral
    SUBCUTANEOUS HORMONE PELLET IMPLANTATION OF ESTRADIOL
    Medications: Estradiol 50 mg pellet 50 mg
    Testosterone 100 mg pellet
    Instructions: Mammography recommended annually by ACOG and ACS for normal risk women over 40. Any patient concerns discussed.
    Disposition: Call or RTC if symptoms worsen or persist.
    Last edited by cyndiann; 01-06-2012 at 03:27 PM. Reason: adding additional information

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by cyndiann View Post

    CPT 11980
    CPT 99396 25
    ICD9 v72.31
    ICD9 627.4
    ICD9 256.31

    This is what has been accepted, but they still say I am missing one or more codes. Does anyone besides myself find these things more than chalenging? Here is the note:

    Chief Complaint: Annual exam

    Pt here for her annual exam, would like to have Pellets Implanted.

    History Of Present Illness:
    This patient requests hormone pellet insert. Indications reviewed and concems about ability to achieve physiologic levels, avoid peaks and troughs, and safety concerns such as bothersome side effects of testosterone have been reviewed.
    In this case the concern is of premature surgical menopause and inability to achieve adequate response from more standard forms of hormone therapy.
    The skin was prepped with betadine and 5 cc of xylocaine placed on anterior abdominal wall. Small nick in skin made with scalpel, the skin gently undermined. Subcutaneous pellet(s) were then inserted into the skin.
    Gentle pressure and a bandaid were applied and patient Instructed to keep the area dean and dry, to apply direct pressure if any bleeding occurs. To call if any concerns.
    The patient is a 44 year old female gravida para.
    Her general health issues include Ovarian Cancer.
    Social history reviewed. Has had marital counseling recently; husband getting testosterone injections. Very stressed about marriage, finances, spouse with health Issues he's not addressing and they run an autodealership so economy has hit very hard

    Past Surgical History: Abdominal hysterectomy with bilateral oopherectomy.

    Medication List
    Estradiol 50 mg pellet
    Spironolactone Oral Tablet 100 mg Testosterone 100 mg pellet
    Valtrex Oral Tablet 1 g
    Wellbutrin SR Oral Tablet Sustained Release 100 mg

    Revievtf of Systems:
    Constitutional - Denies : body aches, night sweats
    HENT - Denies : headaches, dental problems, neck stiffness, oral ulcers
    Breasts - Denies : lumps, tenderness, swelling, nipple discharge, abnormal changes In breast size
    Cardiovascular - Denies : chest pain, syncope, dyspnea on exertion, lower extremity edema, varicosities
    Respiratory - Denies : shortness of breath, cough
    Gastrointestinal - Denies : nausea, vomiting, diarrhea, constipation, abdominal pain, blood In stools, excessive flatulence
    Genitourinary - Denies : urgency, frequency, dysuria, hematuria. Incontinence, decreased libido, dyspareunia, genital sores. Irregular menses, menorrhagia, metrorrhagia, vaginal discharge, significant PMS.
    Integumentary - Denies : rash, changes to existing skin lesions or moles, hirsutism, Thinning hair-alopecia. Bothersome facial hair - age appropriate
    Neurologic - Denies : muscular weakness. Incoordination, tingling or numbness, difficulty concentrating, snoring
    Musculoskeletal - Denies : joint pain, joint swelling, muscle pain, muscle cramps, back pain
    Endocrine - Denies : polyuria, polydipsia, cold intolerance, heat intolerance, central obesity
    Psycliiatric - Denies : anxiety, depression, feeling confused, difficulty sleeping
    Heme-Lymph - Denies : easy bleeding, easy bruising, lymph node enlargement or tenderness
    Allergic-Immunologic - Admits : seasonal allergies

    Vitals:
    BMI is 24.14 kg/m2 .
    BP 100/70 WT 178 lbs 0oz HT 6' 0"

    Physical Examination
    Constitutional - Appearance : well-nourished, well developed, alert, in no acute distress
    Eyes - Conjunctiva/Eyelids : Normal appearance. Sclera : Normal appearacne.

    HENT- Head and Face : Pleasant, symmetrical, normal fades. No hirsutism. Ears : Extemal ears within normal limits. Hearing grossly Intact.
    Neck - Inspection/Palpation : normal appearance, no masses or tenderness. Thyroid : gland size normal, nontender, no nodules or masses present on palpation
    Chest - Respiratory Effort: breathing unlabored.
    Breasts - Inspection of Breasts : breasts symmetrical, no skin changes, no discharge present, no skin retraction present. Palpation of Breasts and Axillae : no masses present on palpation, no breast tenderness. Axillary Lymph Nodes: no lymphadenopathy present
    Gastrointestinal - Abdominal Examination : abdomen nontender to palpation, tone normal without rigidity or guarding, no masses present, umbilicus without lesions well healed scar from surgery. Liver and spleen : no hepatomegaly present, liver nontender to palpation. Hernias : no hernias present
    Genitourinary - External Genitalia : normal appearance for age, no discharge present, no tenderness present, no inflammatory lesions present. Vagina: normal vaginal vault without central or paravaginal defects, no discharge present, no inflammatory lesions present, no masses present. Bladder : nontender to palpation. Cervix: Absent. Uterus: Absent. Adnexa : no adnexal tenderness present, no adnexal masses present No nodularity. Perineum : perineum within normal limits, no evidence of trauma, no rashes or skin lesions present. Anus: anus within normal limits, Rectal: normal sphincter tone, no rectal masses present. Stool/Hemoccult Testing: Office testing not recommended-ACS guidelines normally followed.
    Lymphatic - Lymph Nodes : no other lymphadenopathy present
    Musculoskeletal - Lumbosacral Spine : No visible defects or deformities. Pelvis : No visible defects or deformities. Right.Upper Extremity: Inspection/Palpation: Appears normal. Motor Function: Appears normal. Left Upper Extremity: Inspection/Palpation: Appears normal. Digits and Nails: Appear normal. Range of Motion: Appears normal. Motor Function: Appears normal. Right Lower Extremity: Inspection/Palpation: Appears normal.Range of Motion: Appears normal Left Lower Extremity: Range of Motion : Appears normal
    Skin - General Inspection : no rashes present, no lesions present, no areas of discoloration.
    Scalp : no rashes present, no lesions present, normal hair pattern present Body Hair: general body hair distribution normal female for age. Pubic Hair: Normal for age
    Neurologic/ Psychiatric - Mental Status : altert, pleasant, and articulate. Coordination: coordination normal. Gait and Station : normal gait and station
    Assessment: Premature menopause. Premature Ovarian Failure/Menopause. Annual/Gynecological Exam Routine. Herpes Simplex, prior workup revealed type I genital lesions. Gets occasionally, had called for valtrex script.
    Plan:
    Orders: Mammogram, screening bilateral
    SUBCUTANEOUS HORMONE PELLET IMPLANTATION OF ESTRADIOL
    Medications: Estradiol 50 mg pellet 50 mg
    Testosterone 100 mg pellet
    Instructions: Mammography recommended annually by ACOG and ACS for normal risk women over 40. Any patient concerns discussed.
    Disposition: Call or RTC if symptoms worsen or persist.
    I don't see codes for the pellet supply. From what I could find the testosterone pellet is S0189 and the estradiol pellet is J3490. maybe that is what is missing.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    I tried both suggestions, because that was what my research had said also. That apparently is not what they are looking for. I am giving up. I will probably never purchase a code a round again. Real life is easier.

  4. Unhappy code a round
    It seems that there should be a way to at least know what you are missing. These 5 notes are only worth 1 CEU, and I have only been sucessful at coding 3. I am an OB/GYN coder. This is not right. Does anyone have a contact who can help with this?

  5. Default ccode a round
    Don't worry, you are not alone. I purchased 5 code a rounds to get CEUs for my CENTC, and they have been a trial-and-error nightmare. What I had to do was get really creative and put in codes that were marginal or nonspecific even if the report said something very specific. I wrote some of my other trials in a reply to another thread about code a rounds. I know the code a rounds were last updated in 2010, so you may want to try older code books. Some of the more specific codes we have now did not exist in 2010. I asked my former coding instructor look at the 3 op reports that I am having problems with and we spent 2 hours putting in codes from the correct to the ridiculous. Of 5 Code A Rounds containing 24 op reports and one clinic note, I have been stuck on one op report in 3 rounds so I have only completed 2 rounds. Broaden your use of codes, and you may stumble on the correct code. Do not think too specifically. I found many of my "correct" answers to be nonspecific codes. Don't forget to try V codes. Good luck and don't feel like it is your fault. I actually perform ENT surgeries every week and I can tell you that my Code a Rounds are incorrect. After taking a one week break, I'm going to try to hit my cases again with 2009 coding books. Any other CENTCs out there with any hints?

  6. #6
    Location
    Columbia, MO
    Posts
    12,965
    Default
    He stated a history of ovarian cancer so I would use the V10 code for that. I would not however code the 256.31 since that is early menopause from ovarian failure which is not the case as documented, he states she had a total hyst due to the cancer which caused the menopause, so using the 627.4 and the V10.x should be sufficient. But overall the V 10.x is what I see missing

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
    Default Code around answer
    Here are the codes I used and accepted:
    99396 25
    11980
    V72.31
    256.31
    054.10
    627.4

    Good luck! I have had some trouble with these also!

    Sue Knapp, CPC, COBGC
    Last edited by sknapp56; 06-18-2012 at 11:37 AM.

  8. #8
    Location
    Columbia, MO
    Posts
    12,965
    Default
    Here is my problem with this. While these may have been the ones accepted for the code a round.. I feel this is bad practice and is teaching badly.
    For one thing it clearly states the patient has had a bilateral oophorectomy so there for she cannot have ovarian failure at this time, nor did she have ovarian failure in the past, it was Ovarian cancer. So the 256.31 is not a diagnosis that this patient currently has nor has she ever had based on this note.
    The herpes simplex appears only under the impression, and no where in the patients exam nor complaints is this brought up as an issue nor as a previous issue that is being followed up on, in fact if you read the note it specifically states under the GI exam. "External Genitalia : normal appearance for age, no discharge present, no tenderness present, no inflammatory lesions present." also under The ROS it states ... "Denies : urgency, frequency, dysuria, hematuria. Incontinence, decreased libido, dyspareunia, genital sores.
    There is also no treatment plan for the herpes, therefore I do not see this diagnosis as being this womans issue. Just because a dx is listed in the impression does not mean we code it, it must be within the context of the note as a complication or a condition that is managed controlled or treated. We need to stop assigning dx codes for conditions the patient is not clearly documented as having. I would have sent this back for clarification and I would send a query to the code a round folks regarding this exercise.

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
    Default pellets
    do they want another diagnosis code or cpt code?

  10. #10
    Default Pellets
    We bill for pellets al the time and get paid

    256.31 is a fine dx code but not for this patient....You can use 627.2 and you may want to add v07.4 hormone replacement therapy.

    We purchase pellets and bill for them as well and receive the reimbursement as long as i make sure there is a ndc# on the claim link with the meds.

    Hope this helps
    Last edited by zerry1; 06-20-2012 at 02:22 PM.

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