REIMBURSEMENT ADVISER

■ BY MELANIE WITT, RN, CPC, MA

Postcoital exam denied: need to consider why it was ordered in the Now what? first place. Since this exam is done to measure We performed a postcoital examination fetal well-being, there are several possibilities. Qon a patient. We have always used 89300 To name just a few: ( analysis; presence and/or motility of • complaints of decreased fetal movement sperm including Huhner test [post coital]), (655.73) but now an insurance company has denied • fetal size that is small or large for dates the claim. Any suggestions? (656.53 or 656.63) First you need to determine the rationale • previous intrauterine fetal demise (V23.49) A for the denial. One of the most common • abnormal fetal heart rate (659.73) reasons for denial of a service is an improper • maternal abdominal trauma (659.83, along diagnosis code. Inquire if the payer objected with a diagnosis indicating the injury) to something specific about the code you Whatever the reason for the test, make used. For instance, some insurance compa- sure it is documented; if it is not and the nies will accept a diagnosis of test- records are audited, returning money to the ing (V26.29, other investigation or testing; or payer would be your best-case scenario. The V26.21, testing) as the reason for the worst-case scenario? Accusations of fraud for postcoital test, while others require an infer- billing a service not documented (meaning, tility diagnosis—either female or male. to the payer, that it never happened). Another issue may be that the patient does not have coverage for infertility services, When is an infant including testing. no longer a newborn? If neither of these is the problem, and the We performed a in the payer won’t simply tell you how to bill for the Qoffice. Code 54150 is listed as exam, you might try the Health Care Financing “Circumcision with a clamp on a newborn,” Administration Common Procedure Coding while 54152 is simply “Circumcision with a System (HCPCS) code for this service, Q0115 clamp.” What is the definition of newborn? (post-coital direct, qualitative examinations of “Newborn” refers to a liveborn infant vaginal or cervical mucous). A during the first 25 days, 23 hours, and 59 minutes of life (from the 1972 American Document the reason College of Obstetricians and Gynecologists for a nonstress test book Obstetric-Gynecologic Terminology, edit- I billed a nonstress test (NST) that was ed by Edward C. Hughes, MD). CPT uses Qrejected. The note in the chart says the this same definition. ■ test was nonreactive. What should I do? Should we not have billed the NST at all, or can I just submit a diagnosis of no fetal Ms. Witt, former program manager in the Department of Coding movement? and Nomenclature at the American College of Obstetricians and A nonreactive fetal NST is the finding of Gynecologists, is an independent coding and documentation con- sultant. Reimbursement Adviser reflects the most commonly accepted A the exam—not the reason it was con- interpretations of CPT-4 and ICD-9-CM coding. When in doubt ducted. To justify performing the NST, you on a coding or billing matter, check with your individual payer.

72 OBG MANAGEMENT • July 2004