Polycystic Ovary Syndrome – Diagnosis, Treatment and Coding

Polycystic Ovary Syndrome – Diagnosis, Treatment and Coding

A common disorder affecting 4% to 12% of women of reproductive age, polycystic ovary syndrome (PCOS) can be treated by reducing the symptoms.

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Also known as Stein–Leventhal syndrome or hyperandrogenic anovulation (HA), polycystic ovary syndrome (PCOS) is a complex but common condition related to hormone imbalance of the ovaries. Left untreated, this hormone imbalance can affect everything from a woman’s menstrual cycle, to her appearance, to her ability to have children, to her overall health. According to the Office on Women’s Health (OWH), this health problem affects 1 in 10 women of childbearing age.

Being a condition with different manifestations, PCOS may be treated by a number of different specialists including gynecologists, infertility specialists, endocrinologists or even cardiologists to treat associated cardiovascular diseases.

Medical billing outsourcing companies can provide documentation support to these specialists.

Symptoms and Diagnosis Women with polycystic ovaries may experience a range of symptoms due to elevated male hormone levels such as irregular periods, obesity, acne, excessive hair growth in face and body, weight gain and trouble getting pregnant. Pregnant women with PCOS have higher rates of miscarriage, gestational diabetes, preeclampsia and Cesarean section (C-section).

Although the real cause of PCOS is not yet known, the condition is related to different factors including insulin resistance, increased levels of hormones called androgens, and an irregular menstrual cycle. Insulin resistance is when the body's cells do not respond normally to insulin. As a result, your insulin blood levels become higher than normal. Over time, insulin resistance can lead to type 2 diabetes. The severity of such symptoms can even lead to depression and also increase the risk of developing heart diseases, obstructive sleep apnea, mood disorders, and endometrial cancer particularly if the patient is overweight or obese.

Any single test cannot diagnose PCOS. To diagnose PCOS, you doctor may recommend a physical exam; pelvic exam to check for signs of extra male hormones; pelvic ultrasound (sonogram) to check the ovaries and the thickness of the uterine lining and to detect ovarian cysts; or blood tests to check your androgen hormone levels, all based on your medical history and symptoms.

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For reimbursement for tests and treatment, PCOS can be documented using the codes  E28 - Ovarian dysfunction  E28.2 - Polycystic ovarian syndrome “E28.2” codes are grouped within Diagnostic Related Group(s) such as    

742 Uterine and adnexa procedures for non-malignancy with cc/mcc 743 Uterine and adnexa procedures for non-malignancy without cc/mcc 760 Menstrual and other female reproductive system disorders with cc/mcc 761 Menstrual and other female reproductive system disorders without cc/mcc

Treatment Though there is no cure for PCOS, the symptoms can be managed. Treatment will be based on the symptoms present, other health problems and whether the patient wants to become pregnant.

First-line treatment for women with PCOS includes lifestyle changes, such as diet and exercise. Pharmacologic treatments may be used to correct metabolic abnormalities and anovulation. The types of medicines that treat PCOS and its symptoms include hormonal birth control tablets, anti-androgen medicines and Insulin-sensitizing drugs (Metformin). The role of insulin resistance is often given special attention. Insulin-sensitizing drugs such as biguanide, metformin, pioglitazone, and rosiglitazone that are used to treat diabetes are frequently used in the treatment of PCOS. These drugs help the body respond to insulin, reduce androgen levels and improve ovulation. Restoring ovulation helps make menstrual periods regular and more predictable.

Metformin inhibits hepatic glucose production through multiple effects on glucose metabolism, and it also increases glucose uptake in peripheral tissues and reduces fatty acid oxidation. Metformin therapy can be documented under  Z79.4 Long term (current) use of insulin

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Surgery is recommended, only if the other options do not work. Two types of surgical interventions to treat PCOS are - laparoscopic ovarian drilling and ovarian wedge resection. While laparoscopic ovarian drilling uses electrocautery or a laser to destroy parts of the ovary, through which ovulation can be triggered, an ovarian wedge resection is the surgical removal of part of the ovary, which is thought to help regulate periods and promote normal ovulation.

CPT codes for PCOS surgery include  49322 Under Laparoscopic Procedures on the Abdomen, Peritoneum, and Omentum  58662 Under Laparoscopic Procedures on the Oviduct/Ovary  58920 Under Excision Procedures on the Ovary Some payers will consider 49322 bundled with 58662 for ovarian drilling.

To meet their complex coding tasks, physicians can consider medical coding services provided by an experienced medical billing and coding company. Make sure that the coding specialists are experienced in coding according to the current gynecology medical coding standards.

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