The ICD-10 code for stress incontinence associated with pelvic floor weakness and muscle incoordination in female is N39.3. The CPT (ICD-9) code for stress incontinence in female is 625.6. ("The Web's Free ICD-9-CM & ICD-10-CM Medical Coding Reference", 2016; "CPT Procedure Codes - Medical Procedure Codes", 2016)
The 41 years old female complained urine leakage while coughing, laughing and when lifting heavy objects. She also experiences bladder leakage when lifting her 1-year-old child. The patient smokes and drinks alcohol occasionally.
Review of the coding system to support the claim: First, I searched for the topic on ‘Pelvic muscle weakness’ in the CPT code index. Under that topic, I choose the subcategory ‘Muscle incoordination’. In this subcategory there is a code for urinary incontinence in females.
The patient has not reported the incidence of incontinence before childbirth. Thus, it was inferred that it could be result of pelvic floor weakness associated with childbirth. The assessment technique used includes testing of blood sugar and lipids. Diabetes is a common reason for urinary incontinence. As the problem was not accompanied by pain and other complications, cystoscopy and urethroscopy were not recommended.
My top three differential diagnosis for this condition were: Diabetes mellitus, cystitis and vaginitis. Urine analysis was done to rule out cystitis and vaginitis. The leukocyte count in the urine was less than 5 per ml of urine. The urine was normal and clear straw colored. The fasting sugar levels in the blood were slightly towards the higher side. Fasting blood sugar level in the patient was 115 mg/dl. The patient was recommended to physiotherapy for pelvic exercises and to incorporate lifestyle changes.
The patient’s insurance provider is Medicare. The ICD-9 code: 625.6, is billable and indicates the diagnosis on the reimbursement claim. The physician fee for this claim varies from $198 to $298. Normally 80% of the physician fees is reimbursed in the first phase. This includes charges for any patient follow up made in the future.
References
CPT Procedure Codes - Medical Procedure Codes. (2016). Findacode.com. Retrieved 29 June 2016, from https://www.findacode.com/cpt/cpt-code-set.html
The Web's Free ICD-9-CM & ICD-10-CM Medical Coding Reference. (2016). Icd9data.com. Retrieved 29 June 2016, from http://www.icd9data.com/
