Coding for the female patient in 2002. (Featured Cme topic: Female Patient).

The place where most Americans receive their health care is in physician office practices. A new report from the Centers for Disease Control and Prevention (CDC) examined women's use of ambulatory medical care in 1997 and 1998 and found that women's care differs from men's care in many significant ways. The report highlights the importance of understanding the way that women use health care so that health care providers can be prepared and programs can be developed to meet women's special health care needs. (1)

Visits by younger women were more likely to be to primary care physicians and emergency departments while older women were more likely to see specialists. On average, women made about 4.6 visits a year in 1997 and 1998, ranging from 3.8 for those aged 15 to 44 to about double that for those 65 and older. Utilization rates categorized by major reason for visit showed that the visit rates by women for non-illness (eg, annual examination) were 100% higher than among men, after controlling for age and removing pregnancy-related visits.

The most common diagnostic or screening service for women was blood pressure screening performed in over half of all visits. Pelvic exams were performed during about 14% of the visits and urinalysis in about the same number of visits. The rate of mammography was about 29% lower for women aged 65 and over than for women 45 to 64 years of age. (1)

More than four out of five ambulatory medical care visits by women were made to office-based physicians; the rest were about equally divided between hospital outpatient and emergency departments. (1) The most frequent sources of payment for ambulatory care visits by women were private insurance (50%), Medicare (22%), and Medicaid (9%). The proportion of visits covered by private insurance was 1.3 times as high among white women as among black women. In contrast, the proportion of ambulatory visits by black women covered by Medicaid was more than three times the proportion of Medicaid visits by white women. (1)

The Office of the Inspector General (OIG) released its FY2002 Work Plan in October 2001. As part of the office review, they plan to review the procedure coding of outpatient services billed by a hospital and a physician for the same service. The OIG reports that in a previous review, they identified a 23% nationwide rate of inconsistency between the hospital outpatient department procedure coding and physician procedure coding for the same outpatient service. The review is expected to determine whether these coding differences continue and how they affect the Medicare program. (2)

Coding serves an important function for physician reimbursement, quality review and benchmarking measurement. Correct coding assures that policy regarding health, health care, and the allocation of health care resources is grounded on reliable information.

NEW ICD-9-CM DIAGNOSIS CODES

Premature Menopause (codes 256.31, 256.39)

Code 256.3 has been expanded to differentiate between premature menopause (256.31) and other ovarian failure (256.39), which includes delayed menarche, ovarian hypofunction, and primary ovarian failure NOS.

Abnormal Mammogram (codes 793.80, 793.81, 793.89)

Nonspecific abnormal findings on radio-logic and other examination of breast 793.8 has been expanded by the use of the fifth digit. Code 793.80 Abnormal mammogram - unspecified, 793.81 Mammographic microcalcification, and 793.89 Other abnormal finding on radiologic examination of breast. Code 793.81 is used only for mammographic microcalcification findings, not pathologic findings.

V83 GENETIC CARRIER STATUS (CODES V83.01-V83.02)

Hemophilia A Carrier Status V83.0

V83.01 Asymptomatic hemophilia A carrier and V83.02 Symptomatic hemophilia A carrier. There is a note in the new code subcategory that additional codes for associated disorders or symptoms are to be assigned.

Sunburn (codes 692.71, 692.76, 692.77)

A distinction has been made in the degree of sunburn. The code 692.71 is being revised to specify first-degree sunburn, with two additional codes added to denote second- and third-degree sunburn. A note is also being added to code 692.82 Dermatitis due to other radiation to classify burns from tanning beds.

Stress Fractures (codes 733.93-733.95)

The stress fracture is a traumatic fracture occurring due to repeated stress on the bone, not due to an acute traumatic injury. Pathologic fractures are caused by a physiologic condition that damages the bone, such as neoplasm or osteoporosis. There are now ICD-9-CM codes that may be used to distinguish stress fractures from pathologic fractures. Code 733.93 denotes a stress fracture of the tibia or fibula, 733.94 a stress fracture of the metatarsals, and 733.95 a stress fracture of other bone.

CHANGES TO CPT PROCEDURE CODES FOR 2002

Billing for screening Pap smears and pelvic exams has changed. Since July 1, 2001, average-risk patients are allowed to have screening Pap smears and pelvic exams once every two years, instead of once every three years.

Starting in January 2002, it will be possible to bill a screening mammogram (76092) and a diagnostic mammogram on the same day. In the past, only the diagnostic mammography code 76090 unilateral or 76091 bilateral could be billed in cases where a screening mammography with additional views resulted in comprehensive diagnostic mammography. Now the change in policy makes it possible to bill both a diagnostic mammography and screening mammography on the same day for the same beneficiary. The use of a new modifier -GG attached to the diagnostic mammography code is needed to indicate performance and payment of a screening mammography on the same patient, on the same day. Both ICD-9-CM codes should be used for the screening mammography (V76.12) and the diagnostic mammography (611.72).

The following codes are to be used on mammography claims for Medicare patients after January 1, 2002:

* 76092 - Screening mammography, bilateral (two-view film study of each breast)

* 76085 - Computer-aided detection add-on code for screening mammography (use with 76092)

* 76090 - Diagnostic mammography, unilateral

* 76091 - Diagnostic mammography, bilateral

* G0236 - Computer-aided detection add-on code for diagnostic mammography (use with 76090 or 76091)

* G0202 - Screening mammography, direct digital image, bilateral, all views

* G0204 - Diagnostic mammography, direct digital image, bilateral, all views

* G0206 - Diagnostic mammography, film processed to produce digital image analyzed for potential abnormalities, bilateral, all views.

NEW ICD-9-CM INPATIENT PROCEDURE CODES

Repair of Internal Cervical Os (codes 67.51, 67.59)

Repair of cervical opening defect involves a surgical technique that reinforces the cervical muscle by placing sutures above the opening of the cervix to narrow the cervical canal. There are two approaches to the procedure. The most common approach is through the vagina with a speculum; the other approach is via an abdominal incision. Distinction may be made between the two approaches with the use of the new codes. Code 67.51 is used for a transabdominal approach. Other repairs, including McDonald operation, Shirodkar operation, and transvaginal cerclage will be coded 67.59.

MODIFIERS FOR PHYSICIAN SERVICES

Physicians should be aware that rules for using modifiers could differ depending on the place of service and the payer. Modifier 25 (significant separately identifiable Evaluation & Management service) usage differs for the hospital outpatient setting than for physician office billing. Modifier 24 (unrelated E&M service by the same physician during the postoperative period) is often determined by the diagnosis assigned. The payer defines the "postoperative period"; Medicare's postoperative period is 0, 10, or 90 days, but for other payers it is 30 days. Physicians and office staff should review the CPT book guidelines and Medicare's modifier instructions for additional detail and clarification.

References

(1.) Utilization of Ambulatory Medical care by Women: United States, 1997-1998. Series report 13, No. 149. 51 pp. (PHS) 2001-1720. http://www.cdc.gov/nchs/releases/o1news/newstudy.htm

(2.) The Office of Inspector General FY2002 Work Plan is available at http://www.hhs.gov/oig/wrkpln/2002/Work_Plan_2002.htm

Suggested Reading

1. Another source providing guidance on coding issues: Centers for Medicare & Medicaid Services (CMS) Program Memorandum website: http://www.hcfa. gov/pubforms/transmit/memos/comm_date_dsc.htm

2. Program Memo Transmittal AB-01-144, ICD-9-CM coding for Diagnostic Tests, http:// www.hcfa.gov/pubforms/transmit/memos/comm_date_dsc.htm

3. National Ambulatory Medical care Survey: 1999 Summary. Published July 17, 2001. http://www.cdc.gov/nchs/releases/o1news/olderpat.htm