“CODE THIS!” (Case of the Month)

Multiple Co-Morbidities in Pregnancy in an Established Patient in the Third Trimester

by Lori-Lynne A. Webb, CPC and Renee Allen, MD, MHSc., FACOG

Case Excerpt (summary and narrative of actual case):

31 yo G4P1112 at 34 3/7 weeks EGA (by 8 week ultrasound) presented to L&D with complaints of decreased fetal movement and abdominal pain . On this day she hasn't felt the baby move and came in to OB Triage for evaluation.  After arriving she reported that she felt the baby move three times in the first twenty minutes of being monitored. 

The patient complained of 24 hours of intermittent abdominal pain.  When she arrived she was contracting every five minutes; which corresponded to her intermittent abdominal pain.  She denied vaginal bleeding or loss of fluid.  She reported some recent vaginal discharge evaluated by her private OBGYN and found to be normal (negative wet prep, negative gonorrhea and chlamydia testing). She last had sex 8 weeks ago and her last pelvic exam 2 days ago.

Her pregnancy was complicated by cholestasis, and she has been performing regular fetal kick counts.  The cholestasis of pregnancy was diagnosed several weeks before this triage visit.  She had been on oral ursodiol therapy.  The pregnancy was also complicated by morbid obesity, with a BMI 54, macrosomia, and polyhydramnios ( AFI 26 and EFW >90^th  percentile).. 

Her first delivery in 2010, was by cesarean section at 41 5/7 weeks for arrest of descent.  The operative report was available in her chart.  A low transverse incision was documented.  Her second delivery was a successful VBAC induced at 36 2/7 weeks. Details of the delivery are documented in the EHR . 

Triage course:  The patient was evaluated for preterm labor with serial cervical exams and a fetal fibronectin (FFN), which was negative.  Her initial cervical exam was 2cm and a repeat cervical exam two hours later was unchanged.   Antenatal corticosteroids were considered. The patient was coincidentally fasting for previously planned gestational diabetes screening and an order was placed for a fasting glucose and metabolic panel.  Her fasting glucose was elevated to 112 mg/dl.  A 50gram glucose challenge test was ordered and was also elevated to 189 mg/dl.  Given the potential diagnostic confounding effect of corticosteroids, a diagnosis of gestational diabetes was made without further glucose testing. 

Her systolic blood pressure was elevated intermittently during her evaluation.  She denied headache or visual changes.  She denied right upper quadrant (RUQ) pain.  Her abdominal pain was determined to be contractions. A preeclampsia evaluation was done. HerCMP was normal.  Her protein:creatinine ratio was indeterminate at 0.2 and a 24 hour urine collection was started.

Results Review

The final diagnosis and assessment provided by the OBGYN Hospitalist was: 

1. Preterm contractions: Preterm contractions with preterm cervical dilation to 2/50/-2.  Cervical exam remained unchanged over 2 hours and 2 examinations and the FFN was negative.  Given no cervical change and negative FFN, the OB Hospitalist did not proceed with antenatal corticosteroids (ANCS) secondary to new diagnosis of GDM.  The patient was counseled that antenatal steroids may be recommended later for fetal lung maturity given anticipated delivery at 36-37 weeks due to cholestasis of pregnancy.
2. Decreased fetal movement, resolved shortly after arrival. Patient had a reactive non-stress test (NST) with category I fetal heart tracing.
3. Gestational Diabetes (GDM), diagnosed during this triage visit based on fasting glucose 112mg/dl and 1hr GTT 189 mg/dl.  Plans were made for the patient to receive diabetes education. The patient was instructed to begin blood glucose monitoring and to return to OB Triage immediately if her blood sugars are >200mg/dl.  The basics of a diabetic diet was discussed with the patient with the caveat that more formal and extensive education would be provided from the diabetes education center.
4. Intermittently elevated blood pressures with indeterminate protein:creatinine ratio.  A 24-hour urine protein test was ordered as an outpatient and the collection kit and instructions provided.  Preeclampsia precautions were reviewed.
5. Cholestasis of pregnancy.  Normal LFTs today via CMP.  Delivery plan is for delivery at 36-37 weeks per MFM.  The patient had questions regarding her mode of delivery.  Given that she previously had a successful VBAC and now has a favorable cervix, the patient was encouraged to consider attempting another VBAC and to discuss it with her MFM.

Follow up with her own private OBGYN is scheduled for 3 days after this triage visit.  

As the OB hospitalist, how would your services be coded?

ANSWER:

ICD 10 Diagnosis Coding considerations include:

ICD10-CM     O24.419  Gestational Diabetes

ICD10-CM      O13.3     Elevated blood pressure affecting pregnancy in third trimester, antepartum

ICD10-CM      O47.03    Preterm uterine contractions in third trimester, antepartum

ICD10-CM      O26.613  Cholestasis of Pregnancy  (Liver and biliary tract disorders in pregnancy  third trimester )

Z3A.34           34 weeks gestation of pregnancy

Evaluation and Management Codes (E&M)

99214-25 

CPT codes

59025-26 The Fetal NST CPT code is 59025 with modifier 26 (professional component) – reading and interpretation by physician only.

Coding Brief

The OB/GYN hospitalist in this case correctly assigned, based on the patient’s presenting history, signs, symptoms and clinical examination, diagnoses of gestational diabetes, preterm uterine contractions, elevated blood pressure affecting pregnancy in third trimester and cholestasis of pregnancy.

Under ICD-10, any pregnancy complication diagnosis code must be accompanied by a code in the Z3A family, specifying gestational age. Also per the ICD-10 guidelines, if the trimester is known, it is to be coded, in addition to the weeks of gestation.  In this case Z3A.34 denotes 34 weeks gestation.

An established patient is defined as an individual who has received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.  Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient (OB Triage) or other ambulatory facility.  In the case of OB triage, if this patient was seen by any member of the OBGYN Hospitalist team on a previous date within the last 3 years, these codes would be applicable.

Usually the presenting problems that support CPT code 99214 are of moderate to high severity office or other outpatient established patient visit. Counseling and or coordination of care with other providers or agencies are provided as well. .  In addition, as with all E&M encounters, a face-to-face encounter is always required.

The American Medical Association (AMA) describes the 99214 CPT procedure code as follows:

“Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components:  A detailed history; A detailed examination; Medical decision making of moderate complexity.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.  Usually, the presenting problem(s) are of moderate to high severity.  Physicians typically spend 25-45 minutes face-to-face with the patient and/or family.”

The 99214 CPT code can be used for time based billingwhen certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT 99214 documentation should comply with the rules established by the guidelines referenced above. The three important coding components for an established outpatient clinic note are the:

1. History
2. Physical Exam
3. Medical Decision Making Complexity

Appropriate documentation for this type of encounter requires TWO out of THREE of the following :

1. Comprehensive History
2. Comprehensive Exam
3. Moderate Complexity Medical Decision-Making

For all established office patient billing codes (99211-99215), the highest documented two out of three above components determines the correct level of service code. Compare this with the requirement for the highest documented three out of three above components for new office patient care encounters (99201-99205).  Again, only the highest two out of three components are needed to determine the correct level of care for CPT 99214.

Modifier 25 may be used to identify a significant, separately identifiable E&M service performed by the same physician on the same day as another procedure or service. Specifically, the American Medical Association (AMA) Current Procedural Terminology (CPT) book defines Modifier 25 as a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This modifier is not used to report an E&M service that resulted in a decision to perform surgery. In this case, the NST interpretation also occurred on the same days as the evaluation for abdominal pain and decreased fetal movement.  Documentation that supports the provision of a significant, separately identifiable E&M service must be maintained in the client’s medical record.  And as always, the OB Hospitalist’s documentation has to support the claim that is billed to the insurance carrier. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/Trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/. 

Dr. Renée Allen served as co-author of this column.  She is Chair of the SOGH Coding Committee and is the SOGH Liaison to the ACOG Committee on Health Economics and Coding.  She currently works as an OB/GYN Hospitalist with Mednax/Obstetrix at Eastside Medical Center in Snellville, Georgia. 

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