Billable coding for general medical diagnoses and procedures is a complicated process. Within a subspecialty such as female sexual health, which lacks a clear consensus regarding diagnostic coding for sexual dysfunctions, the process can be even more challenging and frustrating. As such, some women’s healthcare providers do not even treat patients with sexual dysfunction in their practices. The purpose of this very first article in the “Focus on sexual health” department is to shed light on the billable coding process for female sexual dysfunction disorders in order to clarify, if not simplify, this process.
The World Health Organization’s International Classification of Diseases (ICD) is utilized in the United States for diagnostic coding for most diseases and other health problems. However, female sexual dysfunction (FSD) diagnoses were developed through the American Psychiatric Association and are listed in the Diagnostic and Statistical Manual (DSM). A text revision of the fourth edition, the DSM-IV-TR,1 published in 2000, included five categories of FSD: hypoactive sexual desire disorder (HSDD), female sexual arousal disorder, female orgasmic disorder, dyspareunia, and vaginismus. With release of the fifth edition, the DSM-5,2 desire and arousal disorders were merged into one unified diagnostic category—female sexual interest/arousal disorder—and vaginismus and dyspareunia were merged into genito-pelvic pain/penetration disorder (Table 1).1,2 A subcategory of HSDD, sexual aversion disorder, was removed.2
According to the DSM-5, in order to meet diagnostic criteria, a person must experience the FSD condition 75%-100% of the time for at least 6 months.2 In addition, the condition must result in significant distress. The disorder must not better be explained by a nonsexual mental disorder, a consequence of severe relationship distress such as domestic violence, or other significant stressors. Also, a new severity scale, which designates a condition as mild, moderate, or severe, was added to allow for more diagnostic specificity.
Current and future ICD diagnostic codes
With regard to the complicated matter of translating these definitions into billable coding, women’s healthcare providers must consider the landscape of the ninth edition, clinical modification, of the ICD (ICD-9-CM).3 Diagnostic codes are categorized into chapters of different body systems, symptoms, and conditions. One of the chapters is mental and behavioral disorders, which coincides with DSM definitions. This chapter includes the FSD diagnostic codes. When billing for patient care specific to FSD diagnoses, providers will find that these disorders are typically covered through a separate division of a patient’s healthcare plan or that they are not covered at all. To overcome this challenge, providers can find codes in other areas of the ICD-9-CM that cover symptoms of FSD such as low libido and dyspareunia (Table 2).3
To complicate matters further, the tenth edition of the ICD (ICD-10) is slated to be released in October 2015. Whereas previous revisions to the ICD were fairly easy to follow, ICD-10 coding will not resemble the familiar ICD-9 terrain at all. To begin, the first character of each code is a letter of the alphabet, not a number.4 F codes will cover mental, behavioral, and neurodevelopmental disorders. Other chapters of relevance to women’s healthcare providers are E codes for endocrine, nutritional, and metabolic diseases; L codes for diseases of the skin and subcutaneous tissue; M codes for diseases of the musculoskeletal system and connective tissue; N codes for diseases of the genitourinary system; and R codes for symptoms, signs, and abnormal clinical and laboratory findings.4Table 3 compares ICD-9-CM and ICD-10 codes related to FSD (with the latter codes still subject to change) and Table 4 lists additional codes that may apply to female sexual complaints.
Table 5 lists Current Procedural Terminology® (CPT) codes for procedures commonly performed in a sexual health practice. In many cases, though, time spent with female patients reporting sexual complaints can surpass that spent performing hands-on examinations and procedures. In these circumstances, providers should bill based on time spent, assuming that more than 50% of the time spent with the patient was face to face and for counseling. If a procedure is performed on the same day as an evaluation and management visit for a separately identifiable complaint, providers should use modifier 25 so that each element can be billed at 100%.
Although navigating the complicated billable coding process for FSD can be confusing and frustrating, treatment for these conditions is frequently reimbursable. General understanding of ICD and DSM terms and codes is critical to smart billable coding. If uncertain about a particular situation, women’s healthcare providers should consult with a billing and coding specialist.
Brooke M. Faught is a nurse practitioner and the Clinical Director of the Women’s Institute for Sexual Health (WISH), A Division of Urology Associates, in Nashville, Tennessee. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: APA; 2000.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC; APA; 2013.
3. International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) Professional Edition. USA: Elsevier/American Medical Association; 2013.
4. ICD-10-CM: The Complete Official Draft Code Set. USA: American Medical Association; 2014.