Reimbursement Advisor

Easier reimbursement: How the new ICD-9 helps

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Securing payment for HPV testing is now much simpler, thanks to much-needed coordination of diagnostic codes with the revised Bethesda System.


 

Mrs. Smith undergoes a screening Pap smear at her annual exam. It has been several years since her last Pap test. The report indicates atypical glandular cells, favor neoplastic. You ask her to return for further testing. The coding dilemma: Should you report this as cancer in situ (233.1) or atypical cells of undetermined significance “favor dysplasia” (795.02)?

Thanks to the newly revised Pap smear section of the International Classification of Diseases–9th Revision–Clinical Modification (ICD-9-CM), frustrating scenarios like the one above are now a thing of the past.

The updated Pap codes are the most welcome changes to ICD-9 for 2005, but they’re not the only revisions that will ease coding difficulties in the coming year. A clip-and-save chart details the changes most relevant to Ob/Gyn practice.

Reporting Pap smear results

The ambiguous nature of Pap smear coding in recent years stemmed from some unfortunate timing: In October 2001, the codes for abnormal Pap smear (795.0X) were revised to correspond to Bethesda system findings, reported by more than 90% of US laboratories. Just before this revision was implemented, however, the Bethesda Committee revised its terminology, so the new codes no longer matched.

The codes now reflect the hierarchy of conditions as described by Bethesda. Thus, reference to “favor benign” and “favor dysplasia” were removed.

Category 795 was changed to “Other and nonspecific abnormal cytological, histological, immunological and DNA test findings.” Next, the heading for code 795.0 was changed to allow coding for both an abnormal Pap smear and cervical human papillomavirus (HPV).

New codes were added to report findings of a high-grade squamous intraepithelial lesion (HGSIL) and low-grade squamous intraepithelial lesion (LGSIL), and to differentiate between these results from a Pap smear specimen and histologic confirmation of dysplasia from a tissue biopsy.

A few notes:

  • Glandular cell changes are now coded to 795.00. This includes a “favor neoplastic” finding, which solves the dilemma posed by the case example.
  • Unsatisfactory or inadequate smear, previously coded with 795.09, is now 795.08.
  • Code 795.09 is now used when a DNA test indicates a low risk for HPV (HPV types 6 and 11)
  • When reporting 795.05 or 795.09, use an additional code for the associated HPV (079.4).
Why these revisions were crucial. Without a code for “atypical squamous cells–cannot rule out high-grade squamous intraepithelial lesions” (ASC-H) versus “atypical squamous cells–undetermined significance” (ASC-US), it was difficult to establish the medical need for HPV tests. The American Society for Colposcopy and Cervical Pathology recommends HPV testing for ASC-US, but not for ASC-H, which should proceed to follow-up colposcopy.

The revision also clarifies that category 795 diagnostic codes are not used for cervical intraepithelial neoplasia (CIN) or dysplasia pathology results.

CIN or dysplasia

For tissue biopsy pathology results indicating CIN 3 or severe dysplasia of the cervix, use code 233.1. For CIN 1 or 2 or mild to moderate dysplasia, use one of the expanded dysplasia codes from the 622.1 series.

Remember: The dysplasia codes are reported as a result of histologic confirmation; codes 795.00 to 795.09 involve a cytologic examination only.

Genital prolapse: more detail on the cause

Previously, code 618.0 covered a range of conditions, from cystocele to vaginal prolapse. However, since CPT is more specific about the various prolapse-repair procedures, ACOG requested an expansion of this code to provide additional detail.

Note, also, that a new code for overflow incontinence, 788.38, was added.

Female genital mutilation

A new subcategory—629.2, female genital mutilation (FGM) status—includes codes representing the range of FGM procedures, from partial clitoris amputation to the procedure known as infibulation.

Use these codes for a primary diagnosis in a nonpregnant patient seeking treatment to correct the mutilation, or as a secondary diagnosis when the patient is currently pregnant, or to medically justify cesarean delivery or a complicated vaginal delivery.

Endometrial hyperplasia

Code 621.3, previously used to report endometrial cystic hyperplasia, has been expanded to 4 new codes.

Peripartum cardiomyopathy

Code 648.6X (other cardiovascular diseases) now specifically excludes peripartum cardiomyopathy, which is coded 674.5X.

Diabetes mellitus

Diabetes is no longer termed insulin-dependent and non–insulin-dependent, but rather type I or type II (differentiated by the functioning of pancreatic beta cells, not by insulin use). Thus, the fifth-digit subclassification used with the diabetes codes in category 250 was revised as follows:

  • 0–type II or unspecified type, not stated as uncontrolled
  • 1–type I (juvenile type), not stated as uncontrolled
  • 2–type II or unspecified type, uncontrolled
  • 3–type I (juvenile type), uncontrolled

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