Health Information Management

Consider two options for coding Rho(D) immune globulin given in pregnancy

JustCoding News: Outpatient, June 13, 2012

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by Lori-Lynne A, Webb, COBGC, CPC, CCS-P, CCP, CHDA

Rho(D) immune globulin is the serum globulin extracted from human blood. It can also be a recombinant immune globulin product created through genetic manipulation of human and/or animal protein. Rh plays an important role in the health of a pregnant patient and her developing fetus.
 
Karl Landsteiner and Alexander Wiener discovered Rh blood types in 1940 and since then researchers have learned a lot about the genetic complexities of Rh and blood typing in relationship to fetal and maternal well being. The Rh system was initially named after rhesus monkeys, since they were the initial research subjects (and because rhesus monkey blood shares similar qualities with human blood). Researchers determined that if the antiserum agglutinates the red cells a person is considered Rh-positive and if it does not he or she is  Rh-negative.
 
From a clinical standpoint, the Rh factor of positive and negative can lead to problems between a mother and the developing fetus, a condition known as mother-fetus incompatibility. This occurs when the mother is Rh-negative and the fetus is Rh-positive. Amazingly enough, these antibodies can cross the placenta and destroy fetal red blood cells. The risk for this happening increases with each pregnancy.
 
To help prevent these complications during pregnancy, physicians routinely order the pregnant patient to undergo testing to determine the Rh and ABO blood typing. Once this has been completed, the physician will then determine whether the patient should receive the Rho(D) immune globulin.
 
The American College of Obstetricians and Gynecologists (ACOG) has developed the following standard guidelines for the administration of the Rho(D) immune globulin product:
 
  • The first dose of Rho(D) immune globulin is to be given at 28 weeks gestation(earlier if there’s been an invasive event)
  • A postpartum dose given within 72 hours of delivery
 
Coding options
As a coder, you need to understand the documentation requirements for the administration of Rho(D) immune globulin, and how to bill and code for it appropriately. This is where the coding of the product becomes somewhat complex. Coders have two different options and perspectives to consider.
 
The CPT ® Manual identifies the Rho(D) immune globulin serum with these three codes:
 
  • 90384, Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use
  • 90385, Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use
  • 90386, Rho(D) immune globulin (RhIgIV), human, for intravenous use
 
To code and bill the serum itself, CPT directs coders to report the administration of the serum with codes 96365-96368, 96372, 96374, or 96375 as appropriate. CPT also instructs coders not to append modifier -51 (multiple procedures) when the providers administers Rho(D) with another procedure.
 
Rho(D) diagnosis coding
 
The next factor to consider when coding Rho(D) in pregnancy is to determine the correct diagnosis to be reported with the service rendered. The most common ICD-9-CM diagnose codes for a pregnant patient with the need for a Rho(D) are:
 
  • V07.2, Need for prophylactic immunotherapy
  • V22.1, Supervision of other normal pregnancy
  • 656.10, Rhesus isoimmunization unspecified as to episode of care in pregnancy
  • 656.11, Rhesus isoimmunization affecting management of mother, delivered
  • 656.13, Rhesus isoimmunization affecting management of mother, antepartum condition
 
However, many other pregnancy diagnoses would denote the need for a Rho(D) injection. The provider must clearly document the diagnosis for the coder to accurately code and bill for the procedure. If the provider does not clearly state the diagnosis, the coder should query the provider.
 
As with any and all services, someone in your practice or facility should preauthorize the Rho(D) injection first with the insurance carrier/third party payer. During the preauthorization process, , ask the carrier how it wants the service coded. This will help you correctly code and bill for this up front=, and avoid payment and coding denials later .
 
Coding examples
In an office or outpatient practice, you would report the following ICD-9-CM diagnosis codes and CPT codes:
  • V07.2, Need for prophylactic immunotherapy
  • V22.1, Supervision of other normal pregnancy
  • 90384, Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use (e.g. serum itself)
  • 96372, therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (e.g. injection of the serum)
 
However, CMS in the Medicare Part B Physician Fee Schedule does not recognize the coding or payment for CPT codes 90384, 90385, and 90386. CMS does however recognize the HCPCS codes for Rho(D) as shown below.
 
  • J2788, injection, Rho(D) immune globulin, human, minidose, 50 mcg (250 i.u.)
  • J2790, injection, Rho(D) immune globulin, human, full dose, 300 mcg (1500 i.u.)
  • J2791, injection, Rho(D) immune globulin (human), (Rhophylac), intramuscular or intravenous, 100 IU
  • J2792, injection, Rho(D) immune globulin, intravenous, human, solvent detergent, 100 IU
If you choose to bill HCPCS codes J2788–J2792, you will need to code and bill for the injection of the serum with either the CPT injection code(s) 96365€–96368, 96372, 96374, or 96375 as appropriate, or with the ICD-9-CM Volume 3 procedure code 99.11 (injection of Rh immune globulin).
 
In an office or outpatient practice, you would still report ICD-9-CM codes V07.2 and V22.1 with HCPCS code J2790 and CPT code 96372
 
For either an inpatient of outpatient facility, coders would report ICD-9-CM codes V07.2 and V22.1 with HCPCS code J2790 and ICD-9-CM Volume 3 code 99.11.
 
This creates a problem because both methods of coding are correct. It’s up to the coder to determine how to code the service based upon how the third party payer will reimburse for the service.
 
 
ICD-10 coding considerations
 
How will the codes change under ICD-10-CM? ICD-10-CM will provide coders with more diagnosis coding options:
 
  • O36.011, maternal care for anti-D [Rh] antibodies, first trimester
  • O36.012, maternal care for anti-D [Rh] antibodies, second trimester
  • O36.013, maternal care for anti-D [Rh] antibodies, third trimester
  • O36.019, maternal care for anti-D [Rh] antibodies, unspecified trimester
  • O36.091, maternal care for other rhesus isoimmunization, first trimester
  • O36.092, maternal care for other rhesus isoimmunization, second trimester
  • O36.093, maternal care for other rhesus isoimmunization, third trimester
  • O36.099, maternal care for other rhesus isoimmunization, unspecified trimester
 
Note that these codes all require a seventh character to identify the fetus for which the code applies.
0, not applicable or unspecified
1, fetus 1
2, fetus 2
3, fetus 3
4, fetus 4
5, fetus 5
9, other fetus
 
The appropriate code from category O30 (multiple gestation) must also be assigned when assigning a code from category O36 that has a seventh character of 1 through 9.
 
Coders also need to report code Z23 (encounter for immunization). This code includes two notes:
  • Code first any routine childhood examination
  • Procedure codes are required to identify the types of immunizations given
Physician documentation criteria
 
Rho(D) serum has specific and appropriate uses. A provider needs to clearly document the medical necessity of the injection of Rho(D) serum. This includes:
  • Administration to Rh-negative women not previously sensitized to the Rho(D) factor, unless the father or baby is conclusively Rh-negative
  • Delivery of an Rh-positive baby irrespective of the ABO groups of the mother and baby
  • Antepartum prophylaxis at 26 to 28 weeks of gestation
  • Antepartum fetal-maternal hemorrhage (suspected or proven) as a result of placenta previa, amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling, other obstetrical manipulative procedure (e.g.,version), or abdominal trauma
  • Actual or threatened pregnancy loss at any stage of gestation
  • Ectopic pregnancy
Editor’s note: Webb is a coder at St. Alphonsus Regional Medical Center in Boise, Idaho, and an AHIMA-certified ICD-10-CM/PCS trainer.Email her at LORIWEBB@sarmc.org or webbservices.lori@gmail.com.
 

 



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