ICD-10-CM documentation and coding for GYN procedures

In 2 months, the new coding set will become the only accepted format for diagnostic coding on medical claims. By now, most clinicians and their staffs should have begun the training process, including the examination of current documentation patterns, to ensure that the more specific ­International Classification of Diseases, 10th Revision, ­Clinical Modification (ICD-10-CM) codes can be reported.

In 2014, I informed you about the more general changes that are to come in the format and ideas for preparation.¹ But now it is time to get down to the nitty-gritty (or granu­larity, if you prefer) of this coding format to ensure correct coding every time for your gynecology services. A separate article will appear in the September 2015 issue of OBG Management to describe diagnostic coding for obstetric care.

No wheel reinvention necessary
Many of the guidelines for ICD-9-CM will transfer over to ICD-10-CM, so it will not be necessary to reinvent the wheel—but there are important changes that will affect both your documentation and payers’ requirements for the highest level of specificity. There also will be some instructions in the tabular section of ICD-10-CM that will let you know whether a combination of codes can or cannot be reported together (called “excludes” notes). In the beginning, this process may require additional communication between practice staff and clinicians.

However, if your practice has prepared a teaching document that outlines currently used codes and compares them with ICD-10-CM code choices and provides comments in regard to issues such as code combinations, conversion to the new system should be almost seamless.

Remember, the documentation of the clinician drives the selection of the code. The less information provided, the less specificity—and the result may be increased ­denials due to medical necessity for procedures and treatments.

Most reported codes will begin with “N”
Although the format of the codes will change under ICD-10-CM, diagnostic reporting will remain the same for most of the gynecologic conditions reported, and clinicians should be aware that the codes they will be reporting mainly will come from those that begin with “N.” One advantage: None of these codes require a 7th character or utilize the “x” placeholder code. In fact, the majority of codes from this chapter will have a one-to-one counterpart in the ICD-9-CM codes. A few exceptions are outlined below.

In addition to the core of “N” codes, a handful of codes will come from other chapters to capture reasons for a gynecologic encounter or surgery. For instance, “Z” codes will be reported for encounters for reasons other than illness and include codes for contraceptive and procreative management, general counseling, history of diseases, preventive gynecologic examinations, and screening scenarios, to name just a few. “R” codes will be used most often for general signs and symptoms, such as abdominal pain or nausea and vomiting.

Your documentation will need to change in some important areas
When you see a patient for an injury to the urinary or pelvic organs that is not a complication of a procedure, or for a complication of a genitourinary prosthetic device, implant, or graft, you will need to document whether this is an initial or subsequent encounter or a sequela. This information is added as a 7th alpha character (a = initial, d = subsequent, s = sequela).

ICD-10-CM defines an initial encounter as the time period in which the patient is actively being treated. A subsequent encounter would be reported after the patient’s active treatment, while she is receiving routine care during the healing or recovery phase. For instance, you would report the encounter as subsequent when the patient is seen after her surgery for an injury to the ovary due to an automobile accident, but you would report an initial encounter for all visits through the surgical date of service when a patient presents with symptoms of mesh erosion requiring surgery. Sequela refers to a condition that developed as a result of another condition. For instance, if the patient’s intrauterine device (IUD) becomes embedded in the ostium due to an undetected uterine fibroid, that is a sequela.

The requirement to indicate laterality also will affect documentation, but this concept is limited to a few codes that might be reported by ObGyns. A designation of the right versus left organ will be required for reported cases of primary, secondary, borderline, or benign tumors of the breast, ovary, fallopian tube, broad ligament, and round ligament, as well as cancer in situ of the breast. However, the terms “bilateral” and “unilateral” are applied only to codes that describe hernias, acquired absence of the ovaries, and injuries to the ovaries and fallopian tubes that are not due to a surgical complication.