Melanie Witt, RN, CPC, MA

PREGNANCY CONFIRMATION

CODING DILEMMA

How do you prevent a “missed period” visit from being incorrectly assigned to the global obstetric package?

Sandra has missed her period and suspects she may be pregnant. You examine her and perform a urine pregnancy test, which confirms the gestation. After giving her a prescription for vitamins and a lab slip for prenatal testing, you ask her to make an appointment in 2 weeks to begin prenatal care.

Now we have a new code (V72.42, pregnancy examination or test) to report the first encounter with the patient at which pregnancy is confirmed. Before the latest batch of new codes, which took effect October 1, the American College of Obstetricians and Gynecologists (ACOG) recommended using ICD-9-CM code 626.8 (missed period) for this office visit, though the “missed period” code implied disease rather than pregnancy. ICD-9-CM rules mandate coding for what is known at the end of a visit. Previously, codes V22.0 or V22.1 (supervision of normal pregnancy) were the only choices.

This pregnancy is not yet being supervised. The visit to confirm pregnancy now will generally be a low-level evaluation and management (E/M) service and is billed outside the global obstetric package because the patient’s pregnancy is not yet being supervised. The new code V72.42 makes this clear.

Changes for the better

That’s just one of the welcome diagnostic code additions in the International Classification of Diseases–9th Edition–Clinical Modification, thanks to the efforts of ACOG.

Besides the new code for pregnancy confirmation, there are codes for:

• multiple pregnancy that has been reduced in number
  
• expanded genetic counseling and testing
  
• oocyte donor, blood typing, and other pregnancy-related codes abnormal Papanicolaou smear has simpler wording.
  
• 2 codes designate cancer therapy: chemotherapy or immunotherapy
  
• family history of osteoporosis
  
• personal history of urinary tract infections
  
• tracking overweight and obese patients
  

…to name just a few.

CERVICAL SCREENING

CODING DILEMMA

What is the best way to code low-risk HPV?

Greta, 42, undergoes cervical sampling by the Papanicolaou test and human papillomavirus (HPV) test; the latter is positive for low-risk HPV types.

Code 795.09, other abnormal Papanicolaou smear of cervix and cervical HPV, has been revised slightly. The example of when to assign this code now reads “cervical low-risk human papillomavirus (HPV) DNA test positive.”

Simpler wording. This revision has simplified the wording of the example, clarifying its use, and does not change how the code is reported.

PHYSICAL EXAM PRIOR TO PROCEDURE

CODING DILEMMA

How do you distinguish preop exams from specialized exams of a specific area or system?

Rachel, 42, is scheduled to undergo uterine artery embolization for fibroids, and you perform the preoperative examination.

V72.83, other specified preoperative examination, and V72.84, preoperative examination, unspecified, have been revised to clarify that they should be reported when a general physical examination was performed prior to surgery or a procedure.

History of specific problems

Several codes have been added to allow ObGyns to use more specific history information relating to the patient’s condition or concerns:

• V13.02, personal history of urinary (tract) infection
  
• V15.88, personal history of fall or risk for falling
  
• V17.81, family history of osteoporosis
  
• V18.9, family history of genetic disease carrier.
  

OBESITY

CODING DILEMMA

What code indicates overweight necessitating intervention?

Alisha is 32 and weighs 180 lb, a heavy load for her 5 ft 2 inch frame. She reports that her health insurance will cover her membership costs for any 1 of several weight loss programs, provided she can demonstrate that she is significantly overweight.

The concerns of the medical community about the increasing prevalence of overweight and obesity (and, more rarely, underweight) and the link to many disease conditions has prompted ICD-9-CM to add several new codes for reporting a woman’s weight.

Supports insurance claims? Code 278.02, overweight, was added and linked to the new codes that report the patient’s body mass index (BMI). The national standards classify a patient as underweight, normal, overweight, obese, or morbidly obese based on the documented BMI; this information may assist patients in receiving treatment for their obesity through insurance coverage.

To calculate BMI, multiply weight in pounds by 703/height in inches squared. The ideal BMI is 20 to 25. Underweight patients have a BMI of 19 or less.

Before the new code for overweight can be entered in Alisha’s case, her BMI would need to be documented at 25 or above. Since her BMI is 32.9, she would fall into the obese category, which includes BMIs of 30 to 34.9. Someone who is morbidly obese has a BMI of 40 or more, or a BMI of more than 35 with 1 or more comorbid conditions such as hypertension, heart disease, high cholesterol, diabetes, severe joint pain, or arthritis.

 

The new BMI codes (V85.0–V85.4) are reported for any adult older than 20. Next year, codes will be added for patients who are between 2 and 20 years of age.

MULTIPLE GESTATION

CODING DILEMMA

Should a pregnancy be coded differently after a fetal reduction procedure?

Mariana, 40, undergoes in vitro fertilization with implantation of 2 embryos, but later, because of her age and health (she has metabolic syndrome), requests fetal reduction for a singleton gestation.

Multifetal pregnancy reduction is billed using CPT code 59866, and we now have a new ICD-9-CM code to characterize such gestations after the procedure: 651.7X, multiple gestation following (elective) fetal reduction.

The last digit can be 0, episode of care unspecified; 1, delivered with or without mention of antepartum condition; or 3, antepartum condition or complication.

High risk remains. Though fetal reduction will generally reduce risk to the remaining fetuses, the pregnancy is still considered high-risk. ICD-9-CM staff have clarified that this code should be reported even if, as in Mariana’s case, the pregnancy is reduced to a singleton gestation, as fetal reduction is a complicating factor.

ABNORMAL GLUCOSE TOLERANCE

CODING DILEMMA

Is there a specific code for elevated glucose tolerance test?

At 28 weeks’ gestation, Rebecca reports symptoms suggesting hyperglycemia, so you order blood glucose testing, which reveals elevated glucose tolerance.

Code 648.8X, abnormal glucose tolerance, has been revised to include conditions classifiable as 790.21 through 790.29, and a note was added to report V58.67 for associated long-term (current) insulin use.

Codes 790.21 through 790.29 are used to report specific abnormal glucose findings and may be added as a secondary diagnosis to clarify the abnormal result in pregnancy. For instance, code 790.21 is reported if the patient has elevated fasting glucose, while 790.22 indicates she has an elevated glucose tolerance test, as in Rebecca’s case.

Other pregancy-related codes

Obstructed labor. In other pregnancy-related changes, ICD-9-CM has clarified use of 660.8X, other causes of obstructed labor, to require an additional code to identify the cause. For instance, if the internal orifice is total obstructed by a tumor, use code 660.8X as the primary diagnosis and 653.8X, disproportion of other origin.

Procreative management. V59.7, donor, egg (oocyte) (ovum) has been added, and includes five 5-digit codes for type of donor. Using them properly requires knowing the age and status (eg, anonymous or not) of the donor. If no information about the donor’s age is available, the unspecified code V59.70 is used. Otherwise the choices are V59.71 and V59.73 for anonymous donors under age 35 and 35 and over, respectively, and V59.72 and V59.74 for donors under age 35 and 35 and over, respectively, whose eggs are to go to a designated recipient.

Blood typing. V72.86, encounter for blood typing, now can be used to report testing of the father when the mother is Rh-negative. This information allows physicians to determine the risk of Rh sensitization in the fetus and decide whether immunoglobulin administration is necessary to prevent it during the remainder of the pregnancy.

PREGNANCY CONFIRMATION

CODING DILEMMA

How do you prevent a “missed period” visit from being incorrectly assigned to the global obstetric package?

Sandra has missed her period and suspects she may be pregnant. You examine her and perform a urine pregnancy test, which confirms the gestation. After giving her a prescription for vitamins and a lab slip for prenatal testing, you ask her to make an appointment in 2 weeks to begin prenatal care.

Now we have a new code (V72.42, pregnancy examination or test) to report the first encounter with the patient at which pregnancy is confirmed. Before the latest batch of new codes, which took effect October 1, the American College of Obstetricians and Gynecologists (ACOG) recommended using ICD-9-CM code 626.8 (missed period) for this office visit, though the “missed period” code implied disease rather than pregnancy. ICD-9-CM rules mandate coding for what is known at the end of a visit. Previously, codes V22.0 or V22.1 (supervision of normal pregnancy) were the only choices.

This pregnancy is not yet being supervised. The visit to confirm pregnancy now will generally be a low-level evaluation and management (E/M) service and is billed outside the global obstetric package because the patient’s pregnancy is not yet being supervised. The new code V72.42 makes this clear.

Changes for the better

That’s just one of the welcome diagnostic code additions in the International Classification of Diseases–9th Edition–Clinical Modification, thanks to the efforts of ACOG.

Besides the new code for pregnancy confirmation, there are codes for:

• multiple pregnancy that has been reduced in number
  
• expanded genetic counseling and testing
  
• oocyte donor, blood typing, and other pregnancy-related codes abnormal Papanicolaou smear has simpler wording.
  
• 2 codes designate cancer therapy: chemotherapy or immunotherapy
  
• family history of osteoporosis
  
• personal history of urinary tract infections
  
• tracking overweight and obese patients
  

…to name just a few.

CERVICAL SCREENING

CODING DILEMMA

What is the best way to code low-risk HPV?

Greta, 42, undergoes cervical sampling by the Papanicolaou test and human papillomavirus (HPV) test; the latter is positive for low-risk HPV types.

Code 795.09, other abnormal Papanicolaou smear of cervix and cervical HPV, has been revised slightly. The example of when to assign this code now reads “cervical low-risk human papillomavirus (HPV) DNA test positive.”

Simpler wording. This revision has simplified the wording of the example, clarifying its use, and does not change how the code is reported.

PHYSICAL EXAM PRIOR TO PROCEDURE

CODING DILEMMA

How do you distinguish preop exams from specialized exams of a specific area or system?

Rachel, 42, is scheduled to undergo uterine artery embolization for fibroids, and you perform the preoperative examination.

V72.83, other specified preoperative examination, and V72.84, preoperative examination, unspecified, have been revised to clarify that they should be reported when a general physical examination was performed prior to surgery or a procedure.

History of specific problems

Several codes have been added to allow ObGyns to use more specific history information relating to the patient’s condition or concerns:

• V13.02, personal history of urinary (tract) infection
  
• V15.88, personal history of fall or risk for falling
  
• V17.81, family history of osteoporosis
  
• V18.9, family history of genetic disease carrier.
  

OBESITY

CODING DILEMMA

What code indicates overweight necessitating intervention?

Alisha is 32 and weighs 180 lb, a heavy load for her 5 ft 2 inch frame. She reports that her health insurance will cover her membership costs for any 1 of several weight loss programs, provided she can demonstrate that she is significantly overweight.

The concerns of the medical community about the increasing prevalence of overweight and obesity (and, more rarely, underweight) and the link to many disease conditions has prompted ICD-9-CM to add several new codes for reporting a woman’s weight.

Supports insurance claims? Code 278.02, overweight, was added and linked to the new codes that report the patient’s body mass index (BMI). The national standards classify a patient as underweight, normal, overweight, obese, or morbidly obese based on the documented BMI; this information may assist patients in receiving treatment for their obesity through insurance coverage.

To calculate BMI, multiply weight in pounds by 703/height in inches squared. The ideal BMI is 20 to 25. Underweight patients have a BMI of 19 or less.

Before the new code for overweight can be entered in Alisha’s case, her BMI would need to be documented at 25 or above. Since her BMI is 32.9, she would fall into the obese category, which includes BMIs of 30 to 34.9. Someone who is morbidly obese has a BMI of 40 or more, or a BMI of more than 35 with 1 or more comorbid conditions such as hypertension, heart disease, high cholesterol, diabetes, severe joint pain, or arthritis.

 

The new BMI codes (V85.0–V85.4) are reported for any adult older than 20. Next year, codes will be added for patients who are between 2 and 20 years of age.

MULTIPLE GESTATION

CODING DILEMMA

Should a pregnancy be coded differently after a fetal reduction procedure?

Mariana, 40, undergoes in vitro fertilization with implantation of 2 embryos, but later, because of her age and health (she has metabolic syndrome), requests fetal reduction for a singleton gestation.

Multifetal pregnancy reduction is billed using CPT code 59866, and we now have a new ICD-9-CM code to characterize such gestations after the procedure: 651.7X, multiple gestation following (elective) fetal reduction.

The last digit can be 0, episode of care unspecified; 1, delivered with or without mention of antepartum condition; or 3, antepartum condition or complication.

High risk remains. Though fetal reduction will generally reduce risk to the remaining fetuses, the pregnancy is still considered high-risk. ICD-9-CM staff have clarified that this code should be reported even if, as in Mariana’s case, the pregnancy is reduced to a singleton gestation, as fetal reduction is a complicating factor.

ABNORMAL GLUCOSE TOLERANCE

CODING DILEMMA

Is there a specific code for elevated glucose tolerance test?

At 28 weeks’ gestation, Rebecca reports symptoms suggesting hyperglycemia, so you order blood glucose testing, which reveals elevated glucose tolerance.

Code 648.8X, abnormal glucose tolerance, has been revised to include conditions classifiable as 790.21 through 790.29, and a note was added to report V58.67 for associated long-term (current) insulin use.

Codes 790.21 through 790.29 are used to report specific abnormal glucose findings and may be added as a secondary diagnosis to clarify the abnormal result in pregnancy. For instance, code 790.21 is reported if the patient has elevated fasting glucose, while 790.22 indicates she has an elevated glucose tolerance test, as in Rebecca’s case.

Other pregancy-related codes

Obstructed labor. In other pregnancy-related changes, ICD-9-CM has clarified use of 660.8X, other causes of obstructed labor, to require an additional code to identify the cause. For instance, if the internal orifice is total obstructed by a tumor, use code 660.8X as the primary diagnosis and 653.8X, disproportion of other origin.

Procreative management. V59.7, donor, egg (oocyte) (ovum) has been added, and includes five 5-digit codes for type of donor. Using them properly requires knowing the age and status (eg, anonymous or not) of the donor. If no information about the donor’s age is available, the unspecified code V59.70 is used. Otherwise the choices are V59.71 and V59.73 for anonymous donors under age 35 and 35 and over, respectively, and V59.72 and V59.74 for donors under age 35 and 35 and over, respectively, whose eggs are to go to a designated recipient.

Blood typing. V72.86, encounter for blood typing, now can be used to report testing of the father when the mother is Rh-negative. This information allows physicians to determine the risk of Rh sensitization in the fetus and decide whether immunoglobulin administration is necessary to prevent it during the remainder of the pregnancy.

PREGNANCY CONFIRMATION

CODING DILEMMA

How do you prevent a “missed period” visit from being incorrectly assigned to the global obstetric package?

Sandra has missed her period and suspects she may be pregnant. You examine her and perform a urine pregnancy test, which confirms the gestation. After giving her a prescription for vitamins and a lab slip for prenatal testing, you ask her to make an appointment in 2 weeks to begin prenatal care.

Now we have a new code (V72.42, pregnancy examination or test) to report the first encounter with the patient at which pregnancy is confirmed. Before the latest batch of new codes, which took effect October 1, the American College of Obstetricians and Gynecologists (ACOG) recommended using ICD-9-CM code 626.8 (missed period) for this office visit, though the “missed period” code implied disease rather than pregnancy. ICD-9-CM rules mandate coding for what is known at the end of a visit. Previously, codes V22.0 or V22.1 (supervision of normal pregnancy) were the only choices.

This pregnancy is not yet being supervised. The visit to confirm pregnancy now will generally be a low-level evaluation and management (E/M) service and is billed outside the global obstetric package because the patient’s pregnancy is not yet being supervised. The new code V72.42 makes this clear.

Changes for the better

That’s just one of the welcome diagnostic code additions in the International Classification of Diseases–9th Edition–Clinical Modification, thanks to the efforts of ACOG.

Besides the new code for pregnancy confirmation, there are codes for:

• multiple pregnancy that has been reduced in number
  
• expanded genetic counseling and testing
  
• oocyte donor, blood typing, and other pregnancy-related codes abnormal Papanicolaou smear has simpler wording.
  
• 2 codes designate cancer therapy: chemotherapy or immunotherapy
  
• family history of osteoporosis
  
• personal history of urinary tract infections
  
• tracking overweight and obese patients
  

…to name just a few.

CERVICAL SCREENING

CODING DILEMMA

What is the best way to code low-risk HPV?

Greta, 42, undergoes cervical sampling by the Papanicolaou test and human papillomavirus (HPV) test; the latter is positive for low-risk HPV types.

Code 795.09, other abnormal Papanicolaou smear of cervix and cervical HPV, has been revised slightly. The example of when to assign this code now reads “cervical low-risk human papillomavirus (HPV) DNA test positive.”

Simpler wording. This revision has simplified the wording of the example, clarifying its use, and does not change how the code is reported.

PHYSICAL EXAM PRIOR TO PROCEDURE

CODING DILEMMA

How do you distinguish preop exams from specialized exams of a specific area or system?

Rachel, 42, is scheduled to undergo uterine artery embolization for fibroids, and you perform the preoperative examination.

V72.83, other specified preoperative examination, and V72.84, preoperative examination, unspecified, have been revised to clarify that they should be reported when a general physical examination was performed prior to surgery or a procedure.

History of specific problems

Several codes have been added to allow ObGyns to use more specific history information relating to the patient’s condition or concerns:

• V13.02, personal history of urinary (tract) infection
  
• V15.88, personal history of fall or risk for falling
  
• V17.81, family history of osteoporosis
  
• V18.9, family history of genetic disease carrier.
  

OBESITY

CODING DILEMMA

What code indicates overweight necessitating intervention?

Alisha is 32 and weighs 180 lb, a heavy load for her 5 ft 2 inch frame. She reports that her health insurance will cover her membership costs for any 1 of several weight loss programs, provided she can demonstrate that she is significantly overweight.

The concerns of the medical community about the increasing prevalence of overweight and obesity (and, more rarely, underweight) and the link to many disease conditions has prompted ICD-9-CM to add several new codes for reporting a woman’s weight.

Supports insurance claims? Code 278.02, overweight, was added and linked to the new codes that report the patient’s body mass index (BMI). The national standards classify a patient as underweight, normal, overweight, obese, or morbidly obese based on the documented BMI; this information may assist patients in receiving treatment for their obesity through insurance coverage.

To calculate BMI, multiply weight in pounds by 703/height in inches squared. The ideal BMI is 20 to 25. Underweight patients have a BMI of 19 or less.

Before the new code for overweight can be entered in Alisha’s case, her BMI would need to be documented at 25 or above. Since her BMI is 32.9, she would fall into the obese category, which includes BMIs of 30 to 34.9. Someone who is morbidly obese has a BMI of 40 or more, or a BMI of more than 35 with 1 or more comorbid conditions such as hypertension, heart disease, high cholesterol, diabetes, severe joint pain, or arthritis.

 

The new BMI codes (V85.0–V85.4) are reported for any adult older than 20. Next year, codes will be added for patients who are between 2 and 20 years of age.

MULTIPLE GESTATION

CODING DILEMMA

Should a pregnancy be coded differently after a fetal reduction procedure?

Mariana, 40, undergoes in vitro fertilization with implantation of 2 embryos, but later, because of her age and health (she has metabolic syndrome), requests fetal reduction for a singleton gestation.

Multifetal pregnancy reduction is billed using CPT code 59866, and we now have a new ICD-9-CM code to characterize such gestations after the procedure: 651.7X, multiple gestation following (elective) fetal reduction.

The last digit can be 0, episode of care unspecified; 1, delivered with or without mention of antepartum condition; or 3, antepartum condition or complication.

High risk remains. Though fetal reduction will generally reduce risk to the remaining fetuses, the pregnancy is still considered high-risk. ICD-9-CM staff have clarified that this code should be reported even if, as in Mariana’s case, the pregnancy is reduced to a singleton gestation, as fetal reduction is a complicating factor.

ABNORMAL GLUCOSE TOLERANCE

CODING DILEMMA

Is there a specific code for elevated glucose tolerance test?

At 28 weeks’ gestation, Rebecca reports symptoms suggesting hyperglycemia, so you order blood glucose testing, which reveals elevated glucose tolerance.

Code 648.8X, abnormal glucose tolerance, has been revised to include conditions classifiable as 790.21 through 790.29, and a note was added to report V58.67 for associated long-term (current) insulin use.

Codes 790.21 through 790.29 are used to report specific abnormal glucose findings and may be added as a secondary diagnosis to clarify the abnormal result in pregnancy. For instance, code 790.21 is reported if the patient has elevated fasting glucose, while 790.22 indicates she has an elevated glucose tolerance test, as in Rebecca’s case.

Other pregancy-related codes

Obstructed labor. In other pregnancy-related changes, ICD-9-CM has clarified use of 660.8X, other causes of obstructed labor, to require an additional code to identify the cause. For instance, if the internal orifice is total obstructed by a tumor, use code 660.8X as the primary diagnosis and 653.8X, disproportion of other origin.

Procreative management. V59.7, donor, egg (oocyte) (ovum) has been added, and includes five 5-digit codes for type of donor. Using them properly requires knowing the age and status (eg, anonymous or not) of the donor. If no information about the donor’s age is available, the unspecified code V59.70 is used. Otherwise the choices are V59.71 and V59.73 for anonymous donors under age 35 and 35 and over, respectively, and V59.72 and V59.74 for donors under age 35 and 35 and over, respectively, whose eggs are to go to a designated recipient.

Blood typing. V72.86, encounter for blood typing, now can be used to report testing of the father when the mother is Rh-negative. This information allows physicians to determine the risk of Rh sensitization in the fetus and decide whether immunoglobulin administration is necessary to prevent it during the remainder of the pregnancy.

Q What diagnosis code should be used for cytomegalovirus testing in a patient with fetal demise?

A The answer depends on whether the patient was pregnant at the time of the testing. If the patient was pregnant, use code V28.8, other specified antenatal screening; if she was not pregnant, use code V73.89, special screening examination for other specified viral diseases.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What diagnosis code should be used for cytomegalovirus testing in a patient with fetal demise?

A The answer depends on whether the patient was pregnant at the time of the testing. If the patient was pregnant, use code V28.8, other specified antenatal screening; if she was not pregnant, use code V73.89, special screening examination for other specified viral diseases.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q What diagnosis code should be used for cytomegalovirus testing in a patient with fetal demise?

A The answer depends on whether the patient was pregnant at the time of the testing. If the patient was pregnant, use code V28.8, other specified antenatal screening; if she was not pregnant, use code V73.89, special screening examination for other specified viral diseases.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q How can a certified nurse-midwife (CNM) recoup time spent with a laboring patient when a physician performs the delivery? A seminar speaker once indicated CNMs could bill prolonged physician services. For instance, what if the CNM admits the patient for delivery on day 1 and spends 1 hour with her and then on day 2 spends 6 hours with her before the decision is made to proceed to cesarean delivery?

A You can only use the add-on prolonged services codes 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour) and 99357 (each additional 30 minutes) if you are also billing for inpatient care and the record clearly documents the need for the prolonged care. Face-to-face time must be documented to use these codes, not unit/floor time. This is one way that the CNM or family practice physician can bill for labor management when they do not do the delivery.

To report these codes, the typical time included in the base inpatient service you are billing for must be exceeded by 30 minutes. For instance, code 99222 (initial hospital care, requiring a comprehensive history; a comprehensive exam and medical decision making of moderate complexity) has a typical time of 50 minutes. Since in your example the CNM spent only 1 hour face-to-face with the patient on the admission day, the criterion for reporting prolonged services has not been met and code 99356 cannot be billed in addition to 99222.

On the second day, however, prolonged services can be billed. Let’s use the example of 6 hours and assume the subsequent hospital care code billed on that day was 99233 (subsequent hospital care, requiring high complexity of medical decision making and a detailed history or exam). The typical time for this code is 35 minutes.

To determine billable prolonged service time, subtract typical time from the total face-to-face time (in this case 360 minutes), then subtract 30 because the first 30 minutes of prolonged time is not reported (360–35–30=295). Thus on day 2 you could bill 99233, plus 99356×1 for the first hour of prolonged service, and 99357×8 for the 8 remaining half-hour increments of prolonged time.

Two caveats, however. First, CPT nomenclature for the prolonged services codes indicate “physician service,” which means that some payers may not reimburse for prolonged services unless provided by a physician.

Second, if the CNM is unable to bill for the global service, but instead must itemize the services provided by billing separately for antepartum care (eg, 59426, antepartum care only; 7 or more visits) and postpartum care (59430, postpartum care only [separate procedure]), some payers may include the time spent with the laboring patient as part of the antepartum services. Check with the individual payer to see if they have a written policy regarding this situation.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q How can a certified nurse-midwife (CNM) recoup time spent with a laboring patient when a physician performs the delivery? A seminar speaker once indicated CNMs could bill prolonged physician services. For instance, what if the CNM admits the patient for delivery on day 1 and spends 1 hour with her and then on day 2 spends 6 hours with her before the decision is made to proceed to cesarean delivery?

A You can only use the add-on prolonged services codes 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour) and 99357 (each additional 30 minutes) if you are also billing for inpatient care and the record clearly documents the need for the prolonged care. Face-to-face time must be documented to use these codes, not unit/floor time. This is one way that the CNM or family practice physician can bill for labor management when they do not do the delivery.

To report these codes, the typical time included in the base inpatient service you are billing for must be exceeded by 30 minutes. For instance, code 99222 (initial hospital care, requiring a comprehensive history; a comprehensive exam and medical decision making of moderate complexity) has a typical time of 50 minutes. Since in your example the CNM spent only 1 hour face-to-face with the patient on the admission day, the criterion for reporting prolonged services has not been met and code 99356 cannot be billed in addition to 99222.

On the second day, however, prolonged services can be billed. Let’s use the example of 6 hours and assume the subsequent hospital care code billed on that day was 99233 (subsequent hospital care, requiring high complexity of medical decision making and a detailed history or exam). The typical time for this code is 35 minutes.

To determine billable prolonged service time, subtract typical time from the total face-to-face time (in this case 360 minutes), then subtract 30 because the first 30 minutes of prolonged time is not reported (360–35–30=295). Thus on day 2 you could bill 99233, plus 99356×1 for the first hour of prolonged service, and 99357×8 for the 8 remaining half-hour increments of prolonged time.

Two caveats, however. First, CPT nomenclature for the prolonged services codes indicate “physician service,” which means that some payers may not reimburse for prolonged services unless provided by a physician.

Second, if the CNM is unable to bill for the global service, but instead must itemize the services provided by billing separately for antepartum care (eg, 59426, antepartum care only; 7 or more visits) and postpartum care (59430, postpartum care only [separate procedure]), some payers may include the time spent with the laboring patient as part of the antepartum services. Check with the individual payer to see if they have a written policy regarding this situation.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q How can a certified nurse-midwife (CNM) recoup time spent with a laboring patient when a physician performs the delivery? A seminar speaker once indicated CNMs could bill prolonged physician services. For instance, what if the CNM admits the patient for delivery on day 1 and spends 1 hour with her and then on day 2 spends 6 hours with her before the decision is made to proceed to cesarean delivery?

A You can only use the add-on prolonged services codes 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour) and 99357 (each additional 30 minutes) if you are also billing for inpatient care and the record clearly documents the need for the prolonged care. Face-to-face time must be documented to use these codes, not unit/floor time. This is one way that the CNM or family practice physician can bill for labor management when they do not do the delivery.

To report these codes, the typical time included in the base inpatient service you are billing for must be exceeded by 30 minutes. For instance, code 99222 (initial hospital care, requiring a comprehensive history; a comprehensive exam and medical decision making of moderate complexity) has a typical time of 50 minutes. Since in your example the CNM spent only 1 hour face-to-face with the patient on the admission day, the criterion for reporting prolonged services has not been met and code 99356 cannot be billed in addition to 99222.

On the second day, however, prolonged services can be billed. Let’s use the example of 6 hours and assume the subsequent hospital care code billed on that day was 99233 (subsequent hospital care, requiring high complexity of medical decision making and a detailed history or exam). The typical time for this code is 35 minutes.

To determine billable prolonged service time, subtract typical time from the total face-to-face time (in this case 360 minutes), then subtract 30 because the first 30 minutes of prolonged time is not reported (360–35–30=295). Thus on day 2 you could bill 99233, plus 99356×1 for the first hour of prolonged service, and 99357×8 for the 8 remaining half-hour increments of prolonged time.

Two caveats, however. First, CPT nomenclature for the prolonged services codes indicate “physician service,” which means that some payers may not reimburse for prolonged services unless provided by a physician.

Second, if the CNM is unable to bill for the global service, but instead must itemize the services provided by billing separately for antepartum care (eg, 59426, antepartum care only; 7 or more visits) and postpartum care (59430, postpartum care only [separate procedure]), some payers may include the time spent with the laboring patient as part of the antepartum services. Check with the individual payer to see if they have a written policy regarding this situation.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Our ObGyn providers perform endometrial ablations in the outpatient department of our local hospital. Medicare and some other major carriers state we are to be reimbursed at the facility fee reimbursement rate. We disagree with this reduction in payment and would like some guidance on how to dispute this discount.

A The payment level is determined by the place of service, not the category of health care professional performing the surgery.

In the office setting the practice expense portion of the relative value assigned to a procedure is higher than when the procedure is performed in an outpatient setting, which does not incur the expense of supplies, treatment room, anesthesia, and equipment. The physician is still reimbursed the same for the physician work and malpractice elements of the procedure’s relative value, but the total RVU is less because the practice expense portion is less.

A physician would be paid at the lower RVU level for a facility setting, for performing a procedure in a hospital outpatient department, under Medicare rules, since the outpatient facility has incurred the expenses of staffing the procedure as well as the expensive disposable equipment.

The only exception to this rule is when a procedure performed in this setting does not appear on the ambulatory surgical center (ASC) list of procedures. In that case, the higher nonfacility fee allowance would be reimbursed. Unfortunately, both codes for an endometrial ablation—58353 (endometrial ablation, thermal, without hysteroscopic guidance) and 58563 (hysteroscopy surgical; with endometrial ablation)—appear on the ASC list.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Our ObGyn providers perform endometrial ablations in the outpatient department of our local hospital. Medicare and some other major carriers state we are to be reimbursed at the facility fee reimbursement rate. We disagree with this reduction in payment and would like some guidance on how to dispute this discount.

A The payment level is determined by the place of service, not the category of health care professional performing the surgery.

In the office setting the practice expense portion of the relative value assigned to a procedure is higher than when the procedure is performed in an outpatient setting, which does not incur the expense of supplies, treatment room, anesthesia, and equipment. The physician is still reimbursed the same for the physician work and malpractice elements of the procedure’s relative value, but the total RVU is less because the practice expense portion is less.

A physician would be paid at the lower RVU level for a facility setting, for performing a procedure in a hospital outpatient department, under Medicare rules, since the outpatient facility has incurred the expenses of staffing the procedure as well as the expensive disposable equipment.

The only exception to this rule is when a procedure performed in this setting does not appear on the ambulatory surgical center (ASC) list of procedures. In that case, the higher nonfacility fee allowance would be reimbursed. Unfortunately, both codes for an endometrial ablation—58353 (endometrial ablation, thermal, without hysteroscopic guidance) and 58563 (hysteroscopy surgical; with endometrial ablation)—appear on the ASC list.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Our ObGyn providers perform endometrial ablations in the outpatient department of our local hospital. Medicare and some other major carriers state we are to be reimbursed at the facility fee reimbursement rate. We disagree with this reduction in payment and would like some guidance on how to dispute this discount.

A The payment level is determined by the place of service, not the category of health care professional performing the surgery.

In the office setting the practice expense portion of the relative value assigned to a procedure is higher than when the procedure is performed in an outpatient setting, which does not incur the expense of supplies, treatment room, anesthesia, and equipment. The physician is still reimbursed the same for the physician work and malpractice elements of the procedure’s relative value, but the total RVU is less because the practice expense portion is less.

A physician would be paid at the lower RVU level for a facility setting, for performing a procedure in a hospital outpatient department, under Medicare rules, since the outpatient facility has incurred the expenses of staffing the procedure as well as the expensive disposable equipment.

The only exception to this rule is when a procedure performed in this setting does not appear on the ambulatory surgical center (ASC) list of procedures. In that case, the higher nonfacility fee allowance would be reimbursed. Unfortunately, both codes for an endometrial ablation—58353 (endometrial ablation, thermal, without hysteroscopic guidance) and 58563 (hysteroscopy surgical; with endometrial ablation)—appear on the ASC list.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Would the excision of a single lesion for a diagnosis of VIN III be excision of a malignant lesion?

A No. A diagnosis of VIN III means that the patient has an intraepithelial neoplasia, and the diagnostic code would be 233.3, carcinoma in situ of the vulva. However, VIN III leads to invasive cancer in only about 4% of women, so this condition is considered preinvasive, not cancerous.

Unless the physician has indicated in the operative note that a simple partial vulvectomy was performed (eg, with more extensive lesions), I would pick codes that represent a benign or premalignant lesion.

If the lesion was excised, the code choice would be one of 11420 through 11426 (excision, benign lesion including margins, except skin tags [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter […]). Each code in this series specifies a different lesion diameter (≤0.5 cm up to >4.0 cm); you would select the code based on the greatest clinical diameter of the lesion plus the margin required for complete excision.

If the lesion was destroyed, the code 56501 (destruction of lesion[s], vulva; simple) or 56515 (destruction of lesion[s], vulva; extensive) would be reported instead.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Would the excision of a single lesion for a diagnosis of VIN III be excision of a malignant lesion?

A No. A diagnosis of VIN III means that the patient has an intraepithelial neoplasia, and the diagnostic code would be 233.3, carcinoma in situ of the vulva. However, VIN III leads to invasive cancer in only about 4% of women, so this condition is considered preinvasive, not cancerous.

Unless the physician has indicated in the operative note that a simple partial vulvectomy was performed (eg, with more extensive lesions), I would pick codes that represent a benign or premalignant lesion.

If the lesion was excised, the code choice would be one of 11420 through 11426 (excision, benign lesion including margins, except skin tags [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter […]). Each code in this series specifies a different lesion diameter (≤0.5 cm up to >4.0 cm); you would select the code based on the greatest clinical diameter of the lesion plus the margin required for complete excision.

If the lesion was destroyed, the code 56501 (destruction of lesion[s], vulva; simple) or 56515 (destruction of lesion[s], vulva; extensive) would be reported instead.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Would the excision of a single lesion for a diagnosis of VIN III be excision of a malignant lesion?

A No. A diagnosis of VIN III means that the patient has an intraepithelial neoplasia, and the diagnostic code would be 233.3, carcinoma in situ of the vulva. However, VIN III leads to invasive cancer in only about 4% of women, so this condition is considered preinvasive, not cancerous.

Unless the physician has indicated in the operative note that a simple partial vulvectomy was performed (eg, with more extensive lesions), I would pick codes that represent a benign or premalignant lesion.

If the lesion was excised, the code choice would be one of 11420 through 11426 (excision, benign lesion including margins, except skin tags [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter […]). Each code in this series specifies a different lesion diameter (≤0.5 cm up to >4.0 cm); you would select the code based on the greatest clinical diameter of the lesion plus the margin required for complete excision.

If the lesion was destroyed, the code 56501 (destruction of lesion[s], vulva; simple) or 56515 (destruction of lesion[s], vulva; extensive) would be reported instead.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We billed an A&P repair using CPT code 57260 and perineoplasty with CPT 56810-51. It was denied as bundled. Should I have used modifier -59 (distinct procedure)?

A No. Perineoplasty is the same thing as perineorrhaphy. Since this procedure is included with a posterior repair (code 57250) and you are billing for a combined posterior and anterior repair, the perineoplasty would be included in code 57260 as well.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We billed an A&P repair using CPT code 57260 and perineoplasty with CPT 56810-51. It was denied as bundled. Should I have used modifier -59 (distinct procedure)?

A No. Perineoplasty is the same thing as perineorrhaphy. Since this procedure is included with a posterior repair (code 57250) and you are billing for a combined posterior and anterior repair, the perineoplasty would be included in code 57260 as well.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We billed an A&P repair using CPT code 57260 and perineoplasty with CPT 56810-51. It was denied as bundled. Should I have used modifier -59 (distinct procedure)?

A No. Perineoplasty is the same thing as perineorrhaphy. Since this procedure is included with a posterior repair (code 57250) and you are billing for a combined posterior and anterior repair, the perineoplasty would be included in code 57260 as well.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Have the RVUs originally assigned in November 2004 to 58356 (endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed) been corrected so this set of procedures is now reimbursing more in line with other endometrial ablation methods?

A Yes. Medicare released a transmittal in February 2005 (http://www.cms. hhs.gov/manuals/pm_trans/R475CP.pdf) that outlines changes to the payment file that became effective on April 4, 2005. The nonfacility practice expense relative value was raised to 61.43 RVUs, which means the total RVUs for this code are now 68.63. The relative value for the facility setting is much lower, however, at 9.87 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Have the RVUs originally assigned in November 2004 to 58356 (endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed) been corrected so this set of procedures is now reimbursing more in line with other endometrial ablation methods?

A Yes. Medicare released a transmittal in February 2005 (http://www.cms. hhs.gov/manuals/pm_trans/R475CP.pdf) that outlines changes to the payment file that became effective on April 4, 2005. The nonfacility practice expense relative value was raised to 61.43 RVUs, which means the total RVUs for this code are now 68.63. The relative value for the facility setting is much lower, however, at 9.87 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Have the RVUs originally assigned in November 2004 to 58356 (endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed) been corrected so this set of procedures is now reimbursing more in line with other endometrial ablation methods?

A Yes. Medicare released a transmittal in February 2005 (http://www.cms. hhs.gov/manuals/pm_trans/R475CP.pdf) that outlines changes to the payment file that became effective on April 4, 2005. The nonfacility practice expense relative value was raised to 61.43 RVUs, which means the total RVUs for this code are now 68.63. The relative value for the facility setting is much lower, however, at 9.87 RVUs.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q The new code for total abdominal hysterectomy–bilateral salpingooophorectomy (TAH-BSO) with malignancy, 58956, pays less than some of the other codes for malignancy or hysterectomy. Why?

A If you analyze the procedures included in code 58956 (BSO with total omentectomy, total abdominal hysterectomy for malignancy) and compare those with other codes for malignancy with hysterectomy, you will find 5 codes that have a higher RVU: 58210, 58951, 58952, 58953, and 58954. This is because the procedures associated with the new code involve less work than these other procedures.

For instance, code 58951 includes pelvic and limited paraaortic lymphadenectomy in addition to hysterectomy, BSO, and omentectomy. The code for the radical hysterectomy, 58210, also has a higher RVU than 58956, but again that is because the procedure requires more physician work. With 58956, only a total hysterectomy is performed, but 58210 is for a radical hysterectomy; that is, in addition to the uterus and cervix, the parametrium, uterosacral ligaments, and the upper part of the vagina are removed. In the case of codes 58952 through 58954, these procedures also involve radical dissection for debulking, which involves removal or destruction of intraabdominal or retroperitoneal tumors in addition to all the other work.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q I need CPT codes for the following surgical procedures performed on 1 patient on the same day: transvaginal hysterectomy, anterior pelvic floor reconstruction with Pelvicol graft tissue, posterior colporrhaphy, enterocele repair, and a bilateral vaginal vault suspension with the IVS tunneler system.

A This type of multifaceted surgery can be coded in several different ways, but you need to be aware of the relative value combinations you may come up with for the different options and the reduction that is applied by the payer when more than 2 procedures are reported on 1 patient on the same day.

You have 2 coding options here:

• 58270—Vaginal hysterectomy with enterocele repair
  
• 57260-51—Anterior and posterior (A&P) repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue (no modifier because this is a CPT “add-on” code)
  

or

• 58260—Vaginal hysterectomy
  
• 57265-51—A&P with enterocele repair
  
• 57282-51—Vaginal vault suspension
  
• 57267—Pelvicol graft tissue
  

Each option lists the most extensive procedure first, followed by the additional procedures with decreasing relative value units (RVUs). To decide which coding option is better you will need to know the payer allowables for each and what reduction, if any, the payer applies to the additional procedures. You would also have to be aware of any procedure bundles that are applied by your payer that might be different from those developed by Medicare. If you assumed this payer went by the Medicare relative value system and a 50% reduction for the second and third procedures (the “add-on” should not be discounted by the payer as it is valued based solely on the intraoperative portion for that procedure), the second option would be marginally better.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q A new doctor in our practice performed a minilaparotomy with ovarian cystectomy. Since none of our other physicians use this approach, I’m not sure how to code. Any pointers?

A It depends on what you mean by minilaparotomy. In some procedures the incision is small, but it is still an abdominal incision. In others, a “Hasson” or “open field” technique is used, with a small incision to direct the trocar into the correct position. In this case, CPT previously directed coders to add modifier –22 to the primary laparoscopic procedure. (These instructions appeared in CPT as a note before the laparoscopic procedures were distributed throughout the CPT book.)

However, if your physician always uses this technique for performing laparoscopy, the payer will ignore the –22 modifier.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q A new doctor in our practice performed a minilaparotomy with ovarian cystectomy. Since none of our other physicians use this approach, I’m not sure how to code. Any pointers?

A It depends on what you mean by minilaparotomy. In some procedures the incision is small, but it is still an abdominal incision. In others, a “Hasson” or “open field” technique is used, with a small incision to direct the trocar into the correct position. In this case, CPT previously directed coders to add modifier –22 to the primary laparoscopic procedure. (These instructions appeared in CPT as a note before the laparoscopic procedures were distributed throughout the CPT book.)

However, if your physician always uses this technique for performing laparoscopy, the payer will ignore the –22 modifier.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q A new doctor in our practice performed a minilaparotomy with ovarian cystectomy. Since none of our other physicians use this approach, I’m not sure how to code. Any pointers?

A It depends on what you mean by minilaparotomy. In some procedures the incision is small, but it is still an abdominal incision. In others, a “Hasson” or “open field” technique is used, with a small incision to direct the trocar into the correct position. In this case, CPT previously directed coders to add modifier –22 to the primary laparoscopic procedure. (These instructions appeared in CPT as a note before the laparoscopic procedures were distributed throughout the CPT book.)

However, if your physician always uses this technique for performing laparoscopy, the payer will ignore the –22 modifier.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.