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PROM and global OB care: Billing is all about timing

Q When we manage a patient in the hospital for premature rupture of membranes (PROM), we might decide to treat her medically or, depending on fetal age, progress to delivery at admission. Can we legitimately bill for these inpatient services outside of the global obstetric package?

A As with most issues dealing with obstetric care, the payer has the final word on what can and cannot be billed outside of global care. In the situation you describe or, for that matter, admission for any complication of pregnancy, payers generally reimburse for hospital care that occurs before the date of delivery. That includes admission and subsequent care. If you admit the patient for PROM and she goes on to deliver that day, your chances of being reimbursed for the admission diminish considerably—unless your documentation shows considerable work on your part to stop contractions and labor.

BSO for breast Ca patient—OK to code as CIS surgery?

Q I am planning to perform a laparoscopic bilateral salpingo-oophorectomy for a patient who has breast cancer. She is having surgery because she is unable to tolerate anti-estrogens. I plan on indicating the diagnosis as 233.0 and V50.42. Would these codes be correct for this surgery?

A The answer depends on whether 1) she has breast cancer now or 2) she already had treatment and you are planning the surgery to remove structures that are causing the estrogen risk. Reporting 233.0 (carcinoma in situ of the breast) signifies she has breast cancer now, and is still in treatment. If that is not the case—if treatment for in situ cancer has been completed—she instead has a history of the condition (V10.3). This coding rule can be found in the ICD-9-CM official guidelines.

In any case, your primary diagnosis would be V50.42 (prophylactic organ removal, ovary), followed by V10.3, then followed by V86.1 because she is probably estrogen-receptor positive (meaning that taking anti-estrogens will not prevent the return of cancer).

If she is still being treated for cancer in situ, then 233.0 is correct but V50.42 needs to be the primary diagnosis because, otherwise, you get a mismatch between the diagnosis and the surgery (i.e., it appears that you are performing an oophorectomy because of breast cancer).

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