Avoid Denials: Choose the Right ICD-9 Codes to Support Surgical Treatment of Endometriosis- Published on Sun, Apr 01, 2001
"The key to hassle-free claims for endometriosis care is making sure that each stage of the patients treatment is well-documented, especially the diagnostic reasons supporting additional visits and surgery. Claims for office visits and surgeries that are submitted without sufficient diagnostic support will pend for review, be denied or result in a lengthy appeals process.
Coding Stage One The Complaint
Diagnosis and treatment of endometriosis is a multistage process that begins with the patients initial complaint and usually ends with laparoscopic or sometimes open surgery. A patient with endometriosis may report to her ob/gyns office with one or more symptoms, such as dysmenorrhea (625.3), chronic pelvic pain (625.9), dyspareunia (625.0) or an adnexal mass (789.3x). But many women with endometriosis are asymptomatic, and the physician finds a nodule or mass on examination.
If the patients symptoms are minor or are not causing the patient a lot of pain, such as a minor backache at the time of menstruation, the physician may try the patient on an oral contraceptive, or change the dosage of an existing prescription to see if symptoms are relieved.
The ob/gyn will discuss the patients symptoms and perform either a comprehensive or problem-focused examination that will likely include a diagnostic Pap smear (88141-88167) and other tests to rule out other diseases or disorders. Under those circumstances, the visit for the initial complaint would be coded with an E/M code (99202-99205 or 99212-99215), based on the level of examination and/or history and medical decision-making (MDM).
The Pap smear can be reported separately from the E/M service, as can any blood tests or ultrasound examination (if an ovarian mass is noted on examination) the physician orders. At this point, even if the physician suspects endometriosis, he or she cannot use the ICD-9 codes for endometriosis until it has been diagnosed. Instead, he or she can only code for the symptoms present, not the suspicion of disease. Assuming the physician does not yet have a strong suspicion of endometriosis, he or she may choose to treat the problem less aggressively and monitor the patients condit-ion for a few more weeks or months.
Coding Stage Two If the Problem Persists
If the change in oral contraceptive or other steps taken do not relieve any of the patients symptoms, or she presents with other, more serious symptoms, such as (but not limited to) pelvic pain (625.9) or painful intercourse (625.0), the ob/gyn must take further action. This second E/M visit is coded 99212-99215 (office or other outpatient visit for the E/M of an established patient ...), depending on how much worse the established problem is getting and the degree of MDM and examination provided. The ICD-9 codes reported are for the [...]