by Lori-Lynne A, Webb, COBGC, CPC, CCS-P, CCP, CHDA
ICD-10 implementation will likely be pushed back another year, from October 1, 2013 to October 1, 2014, per CMS. However, we need to continue to learn how this new coding system will change the coding, documentation, reporting, and abstracting functions for coders, billers, and providers of care.
In the ICD-9-CM Volume 3 procedure codes, inpatient coders have had few ultrasound codes from which to choose. These codes are:
- Code 88.78, Diagnostic ultrasound of gravid uterus
- Code 88.79, Other diagnostic ultrasound
- Code 75.1, Diagnostic amniocentesis
- Code 75.34, Other fetal monitoring
- Code 75.35, Other diagnostic procedures on fetus and amnion
- Code 88.96, Other intra-operative magnetic resonance imaging (MRI)
- Code 88.97, MRI of other and unspecified sites
OB ultrasound codes: CPT® to ICD-9-CM Volume 3
In CPT, outpatient coders are “ahead of the game” by having more maternal fetal obstetric ultrasound codes from which to choose. When the cooperating parties formatted and drafted ICD-10-PCS, the process of documenting procedures became very similar to that of CPT. However, the AMA CPT procedural ultrasound codes are much more detailed in regard to anatomy, location, and approach (e.g., trans-vaginal, trans-abdominal) than what ICD-9-CM procedure codes currently offer. ICD-10-PCS will add more choices for coders by differentiating codes by anatomic location, approach, and whether procedures are diagnostic or therapeutic.
The codes below serve as a cross reference between the most common CPT codes for obstetric (OB) ultrasounds used in OB practices, outpatient, observation, and inpatient facility settings and those commonly coded to ICD-9-CM Volume 3.
- CPT code 76801/02 = ICD-9-CM procedure code 88.78
- CPT code 76805, 76810 = ICD-9-CM procedure code 88.78
- CPT code 76811–76817 = ICD-9-CM procedure code 88.78
- CPT code 76818/19 = ICD-9-CM procedure codes 75.34 and 88.78
- CPT code 76820/21 = ICD-9-CM procedure code 75.35
- CPT code 76825–28 = ICD-9-CM procedure code 88.78 or 88.79
- CPT code 76830 = ICD-9-CM procedure code 88.79
In ICD-10-PCS, the OB ultrasound codes will change to reflect the section, body system, root operation, body part, approach, device, and qualifier used in the procedures.
OB codes: ICD-9-CM Volume 3 to ICD-10-PCS
Let’s review the differences between ICD-10-PCS and ICD-9-CM Volume 3.
Step 1: Starting in the ICD-10-PCS index, look at “ultrasonography, fetus,” then choose between first trimester (0–14 weeks), second trimester (14–28 weeks), or third trimester (more than 28 weeks) and single vs. multiple gestation. The codes require the provider to clearly document all of this information.
The ICD-10-PCS index also gives coders a code to consider. However, coders know they should always double check what is listed in the index with what is in the tables.
Step 2: We are referred to the ICD-10-PCS code-set table of BY4, in the tables section of the ICD-10-PCS:
OB coding case study
A patient is brought to ultrasound from labor and delivery. This is a twin gestation pregnancy at 33 weeks and 1/7 days complicated by gestational diabetes. Patient has reported decreased fetal movement over the last 24 hours. A sonographic examination was performed on 12/12/2011 using real time equipment.
The amniotic fluid volume for fetus A appears to be normal. The amniotic fluid volume for fetus B appears to be normal.
INDICATIONS: Twins with reported decreased fetal movement with maternal gestational diabetes mellitus
RESULTS
Fetus # 1 of 2
Vertex presentation
Fetal growth appeared normal
Fetal position = Maternal left
Placenta location = Right lateral
No placenta previa
Placenta grade = II
BIOPHYSICAL PROFILE
Fetus A: Biophysical Profile score was 8/8.
Breathing: 2 Movement: 2 Tone: 2 AFV: 2
Fetus B: Biophysical Profile score was 8/8.
Breathing: 2 Movement: 2 Tone: 2 AFV: 2
IMPRESSION
Twin IUP (Fetus A)
33 weeks and 1 day by dates. 33 weeks and 1 day by this ultrasound.
Fetal position = maternal, left vertex presentation
Fetal growth appeared normal
Estimated fetal weight = 2032 grams Estimated fetal weight = 4 lbs 8 oz
No placenta previa Monochorionic, diamniotic
Twin IUP (Fetus B)
33 weeks and 1 day by dates. 32 weeks and 6 days by this ultrasound.
Fetal position = Superior, Right Transverse presentation Fetal growth appeared normal
Estimated Fetal Weight = 2015 grams Estimated fetal weight = 4 lbs 7 oz
No placenta previa Monochorionic, diamniotic
As we follow the steps outlined above (i.e., going from the index to the tables) for this scenario, we would report code BY4GZZZ.
OB MRI coding
ICD-10-PCS includes procedure codes for MRI while CPT uses unlisted code 76498 (unlisted magnetic resonance procedure [e.g., diagnostic, interventional]). In ICD-9-CM Volume 3, we are guided to code 88.97, MRI of other and unspecified sites.
More obstetricians and gynecologists are using MRI. The Food and Drug Administration still indicates that the safety of MRI with respect to a fetus has not been established. However, some obstetricians or maternal fetal medicine specialists will order an MRI when they determine the risk does not outweigh the gain in some specified critical diagnostic cases (e.g., trauma, fetal anomaly, etc.).
This table (Table #2) shows the options ICD-10-PCS will offer coders as this diagnostic intervention becomes more main stream. Note that the codes for MRI in fetal medicine are found in table BY3 instead of BY4 for ultrasound. This means the choices for the MRI body part are fetal head, heart, thorax, abdomen, spine, extremities, and the entire fetus. The table also includes a choice between “contrast and no contrast”, as well as a qualifier choice of “unenhanced and enhanced” or “none”.
Amniocentesis coding
Another routinely used intervention is amniocentesis. In CPT, coders report an ultrasound code in addition to the procedure code for the amniocentesis:
- CPT code 59012 = ICD-9-CM Volume 3 codes 75.33 and 88.78
- CPT codes 59000, 76946 = ICD-9-CM Volume 3 code 75.01
- CPT code 59001 = ICD-9-CM Volume 3 code 75.99
Consider the following case scenario, which illustrates ICD-10-PCS amniocentesis coding.
Patient is gravida 2 para 1, at 33 weeks. Patient has requested amniocentesis for genetic testing. Patient is prepped and draped in the usual manner; the position of the fetus is located using ultrasound guidance. With real-time ultrasound view, I located a safe place for amniotic aspiration that is safely away from the placenta and fetus. I inserted the amniotic needle through the abdomen, and aspiration of fluid from the amniotic sac is performed. Approximately 1 ounce of amniotic fluid is withdrawn and forwarded to the lab for testing. Following the procedure, the mother, and fetus are monitored as per protocol by ultrasound and fetal non-stress test. Procedure including ultrasound took approximately 60 minutes. Patient was discharged to home without complications.
In ICD-10-PCS we will code the ultrasound from the BY4 ultrasound table (see above), then add an additional procedure code fromthe pregnancy table 109:
Therefore, we would code the above scenario as:
- 10904ZU (for the amniocentesis procedure)
- BY4FZZZ (for the ultrasound procedure)
As we move forward in coding education for ICD-10, we, as coders, need to continually educate ourselves with a strong knowledge base of anatomy, physiology, and diseases processes. We then must encourage and educate our providers to document more clearly and completely regarding medical necessity in medical records. Once these concepts are put into place, a successful transition to ICD-10 will be much easier to accomplish.
Editor’s note: Webb is a coder at St. Alphonsus Regional Medical Center in Boise, Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer.