Check out this article I found while fuming over PCOS being considered "infertility" only and thus not covered by my insurance. Hope others find it as useful as I do (hopefully I can make it work out!). This article was written for medical coders, but maybe showing it to a doctor will help them and whoever does their coding to get PCOS treatments covered. Remember, the doctors want to get paid as badly as we want to be treated!
Are You Using Only 256.4 to Report PCOS? Think Again
Signs and symptoms coding is the key until you have a definitive diagnosis
Too often, carriers refuse a polycystic ovarian syndrome (PCOS) diagnosis because it indicates infertility, and they don’t pay for infertility treatments. But you can get paid for treating suspected PCOS because the patient usually has other symptoms.
PCOS isn’t simply a fertility problem. Unfortunately, many insurance carriers either don’t understand that fact or choose to ignore it.
The problem often arises when an insurance carrier receives a claim listing only a PCOS diagnosis. If the patient has received diagnostic testing or treatment for suspected PCOS, the carrier assumes that the patient is receiving fertility treatment and automatically issues a denial. So by coding the patient’s condition as 256.4 (Polycystic ovaries) before you have a definitive diagnosis, you’ve fallen into a coding trap and effectively denied your practice reimbursement for services rendered to that particular patient.
Code the Chief Complaint First
If you don’t report the initial diagnosis as PCOS, how should you code it? The key is to code the chief complaint. A patient generally doesn’t walk into your office and say, “I have PCOS.” A patient usually walks in and says, “I haven’t had a period in four months. What’s wrong with me?” In that case, look to the codes for irregular menses (626.4) or hypomenorrhea (626.1) or other disorders of menstruation (626.8).
PCOS isn’t always easily diagnosed, and coding the complaints provides certainty. If there’s any question whether the patient has PCOS, you should code the secondary characteristics.
“Never use probable, suspected or rule out for physician diagnosis coding,” says Lynn M. Anderanin, CPC, senior coding consultant for Healthcare Information Services LLC in Des Plaines, Ill. “You must use the signs, symptoms, or a confirmed condition or disease.”
Don’t Overlook Nonmenstrual Complaints
You should be aware of other signs and symptoms associated with possible PCOS. Many (if not most) women with suspected PCOS come to the ob-gyn not because they want to conceive a child, but because they want to treat their physical symptoms, which can include inability to menstruate regularly or at all, excessive hair growth, sudden hair loss, unexplained weight gain, and chronic acne. Many of these women simply want a normal menstrual cycle, not a pregnancy. In fact, women can develop PCOS manifestations throughout their lives, not merely during their childbearing years.
PCOS symptoms can include hirsutism (704.1), alopecia (704.0x), abnormal glucose tolerance test (790.2), cystic acne (706.1), obesity (278.00) and many of the disorders associated with an abnormal lipid panel (272.x).
But remember, Anderanin says, “I always tell my students that the diagnoses describe why the patient is being seen today. The patient may have other conditions, but if they are not related to today’s visit, they should not be used for the diagnosis.”
The bottom line is you have to link the proper diagnosis codes to a procedure. If the ob-gyn provides an E/M service, then the insurance carrier shouldn’t deny payment if you report the signs and symptoms. But what if the physician performs a pelvic ultrasound (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) to see whether a patient’s ovaries really are polycystic? You can’t submit an ICD-9 code for obesity and expect an ultrasound to be covered unless your note says, “Because of obesity, I was unable to perform a proper pelvic exam.” But if the patient also has irregular menses (626.4), you can report that, and the carrier will likely pay for the ultrasound.
“Coders must be careful to code what is documented in the medical record, not to fix the patient’s coverage,” says Peggy Stilley, CPC, office manager for Women’s Healthcare Specialists, an Oklahoma University-based private ob-gyn practice in Tulsa.