Melanie Witt, RN, CPC, MA

Q What code should I use for laparoscopic supracervical hysterectomy? Code 58180 appears to be intended for the abdominal approach.

A CPT rules clearly forbid billing a laparoscopic procedure using a code for the abdominal approach. This leaves you with 2 options: Either use

• existing laparoscopically assisted vaginal hysterectomy codes (58550– 58554) with modifier –52 added to denote a reduced service because the cervix was not removed, or
  
• unlisted laparoscopy code 58579.
  

ACOG is working on new codes for laparoscopic supracervical hysterectomy.

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 code should I use for laparoscopic supracervical hysterectomy? Code 58180 appears to be intended for the abdominal approach.

A CPT rules clearly forbid billing a laparoscopic procedure using a code for the abdominal approach. This leaves you with 2 options: Either use

• existing laparoscopically assisted vaginal hysterectomy codes (58550– 58554) with modifier –52 added to denote a reduced service because the cervix was not removed, or
  
• unlisted laparoscopy code 58579.
  

ACOG is working on new codes for laparoscopic supracervical hysterectomy.

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 code should I use for laparoscopic supracervical hysterectomy? Code 58180 appears to be intended for the abdominal approach.

A CPT rules clearly forbid billing a laparoscopic procedure using a code for the abdominal approach. This leaves you with 2 options: Either use

• existing laparoscopically assisted vaginal hysterectomy codes (58550– 58554) with modifier –52 added to denote a reduced service because the cervix was not removed, or
  
• unlisted laparoscopy code 58579.
  

ACOG is working on new codes for laparoscopic supracervical hysterectomy.

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 patient was admitted to a hospital at 37 weeks’ gestation for preterm labor. She stayed 15 days but did not deliver.

Can the attending physician charge outside the global fee for interpreting non-stress tests (NSTs) during this period? If so, how many readings a day can be billed?

A At 37 weeks, the patient does not have premature labor (644.0x), but “other threatened labor,” which is ICD-9 code 644.13 if she does not go on to deliver during this hospitalization. The physician can bill for the admission and daily rounding, but billing for the NST will depend on whether one was performed.

To bill for 59025, the patient is required to mark the strip to indicate fetal movements throughout the 30 to 40 minutes of the test. It would only be necessary to do so if the physician suspected a fetal problem.

However, if external fetal monitors are being used to count contractions or monitor heart rate, the NST would be billed as part of the exam.

No Limit on Number of Tests, If Medically Needed

If a true NST is performed and documented and the physician has interpreted the results, then the obstetrician can bill for it using 59025–59026. No protocols stipulate a limit for NSTs in a single day, but the payer will likely ask about medical necessity if more than 1 per day is performed—especially if the results are all reassuring and the patient is close to term.

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 patient was admitted to a hospital at 37 weeks’ gestation for preterm labor. She stayed 15 days but did not deliver.

Can the attending physician charge outside the global fee for interpreting non-stress tests (NSTs) during this period? If so, how many readings a day can be billed?

A At 37 weeks, the patient does not have premature labor (644.0x), but “other threatened labor,” which is ICD-9 code 644.13 if she does not go on to deliver during this hospitalization. The physician can bill for the admission and daily rounding, but billing for the NST will depend on whether one was performed.

To bill for 59025, the patient is required to mark the strip to indicate fetal movements throughout the 30 to 40 minutes of the test. It would only be necessary to do so if the physician suspected a fetal problem.

However, if external fetal monitors are being used to count contractions or monitor heart rate, the NST would be billed as part of the exam.

No Limit on Number of Tests, If Medically Needed

If a true NST is performed and documented and the physician has interpreted the results, then the obstetrician can bill for it using 59025–59026. No protocols stipulate a limit for NSTs in a single day, but the payer will likely ask about medical necessity if more than 1 per day is performed—especially if the results are all reassuring and the patient is close to term.

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 patient was admitted to a hospital at 37 weeks’ gestation for preterm labor. She stayed 15 days but did not deliver.

Can the attending physician charge outside the global fee for interpreting non-stress tests (NSTs) during this period? If so, how many readings a day can be billed?

A At 37 weeks, the patient does not have premature labor (644.0x), but “other threatened labor,” which is ICD-9 code 644.13 if she does not go on to deliver during this hospitalization. The physician can bill for the admission and daily rounding, but billing for the NST will depend on whether one was performed.

To bill for 59025, the patient is required to mark the strip to indicate fetal movements throughout the 30 to 40 minutes of the test. It would only be necessary to do so if the physician suspected a fetal problem.

However, if external fetal monitors are being used to count contractions or monitor heart rate, the NST would be billed as part of the exam.

No Limit on Number of Tests, If Medically Needed

If a true NST is performed and documented and the physician has interpreted the results, then the obstetrician can bill for it using 59025–59026. No protocols stipulate a limit for NSTs in a single day, but the payer will likely ask about medical necessity if more than 1 per day is performed—especially if the results are all reassuring and the patient is close to term.

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 patient was sent to a midwife by the physician managing her pregnancy. She was sent to obtain information on midwifery so she could decide whether to transfer care.

Can this visit be billed as a consultation, since the physician asked the midwife to see the patient?

A No. A consultation happens when a physician or other health-care professional asks a physician for an opinion or advice about the patient’s condition. Because a midwife has less training than a physician, a midwife is not allowed to bill for a consultation if asked to see a patient at an MD’s request. Remember, the idea behind the consult is to send the patient to someone with more expertise, not less.

It Was Counseling, Not Consulting

Further, the reason for the patient’s visit was not to seek the midwife’s opinion or advice about the patient’s condition. Rather, the midwife was asked to give the patient information, which is “counseling,” not “consulting.”

In this case, the payer may reimburse the midwife for an evaluation and management (E/M) service. Once the patient becomes an established patient for the pregnancy, the midwife will report the applicable maternity care code(s) for transfer of care for a portion of the pregnancy (eg, 59426 with 59410).

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 patient was sent to a midwife by the physician managing her pregnancy. She was sent to obtain information on midwifery so she could decide whether to transfer care.

Can this visit be billed as a consultation, since the physician asked the midwife to see the patient?

A No. A consultation happens when a physician or other health-care professional asks a physician for an opinion or advice about the patient’s condition. Because a midwife has less training than a physician, a midwife is not allowed to bill for a consultation if asked to see a patient at an MD’s request. Remember, the idea behind the consult is to send the patient to someone with more expertise, not less.

It Was Counseling, Not Consulting

Further, the reason for the patient’s visit was not to seek the midwife’s opinion or advice about the patient’s condition. Rather, the midwife was asked to give the patient information, which is “counseling,” not “consulting.”

In this case, the payer may reimburse the midwife for an evaluation and management (E/M) service. Once the patient becomes an established patient for the pregnancy, the midwife will report the applicable maternity care code(s) for transfer of care for a portion of the pregnancy (eg, 59426 with 59410).

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 patient was sent to a midwife by the physician managing her pregnancy. She was sent to obtain information on midwifery so she could decide whether to transfer care.

Can this visit be billed as a consultation, since the physician asked the midwife to see the patient?

A No. A consultation happens when a physician or other health-care professional asks a physician for an opinion or advice about the patient’s condition. Because a midwife has less training than a physician, a midwife is not allowed to bill for a consultation if asked to see a patient at an MD’s request. Remember, the idea behind the consult is to send the patient to someone with more expertise, not less.

It Was Counseling, Not Consulting

Further, the reason for the patient’s visit was not to seek the midwife’s opinion or advice about the patient’s condition. Rather, the midwife was asked to give the patient information, which is “counseling,” not “consulting.”

In this case, the payer may reimburse the midwife for an evaluation and management (E/M) service. Once the patient becomes an established patient for the pregnancy, the midwife will report the applicable maternity care code(s) for transfer of care for a portion of the pregnancy (eg, 59426 with 59410).

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 When we bill for Pap tests (Q0091), vaginal cultures (87070), and stool guaiac (82270), insurance companies refuse to pay.

They tell me we can collect for obtaining the specimen, but I cannot find the correct CPT codes. How should I proceed?

A It depends on what payer you are billing and whether you have the correct Clinical Laboratories Improvement Act (CLIA) certificate to bill for laboratory procedures.

The code Q0091 was developed by Medicare to reimburse physicians for collecting a Pap smear at the time of an otherwise noncovered service. When they later added the code G0101 for the pelvic and breast exam portion of a preventive visit, they continued to reimburse for the collection as well.

Collection Codes

This collection code is not recognized by all payers, however. In fact, the American College of Obstetricians and Gynecologists (ACOG) has indicated that collection is part of the exam and not a separately billable service. However, some payers will allow you to collect for handling the specimen by using the code 99000.

Lab Codes

As for the lab tests you are billing, all providers are required to have the proper certificate before they can bill for laboratory tests. By billing the lab codes, you are telling the payer you are qualified to perform these tests and that you did, in fact, perform them. Once again, there is no collection code for either of these tests. Code 82270, which is a waived test, can be performed by the physician in the office, and the collection of the stool specimen is an integral part of the code. A waived test, by the way, still requires a certificate (visit www.cms.hhs.gov/clia/certypes.asp for definitions of the various certificate levels).

Culture Codes

The culture code you are using, 87070, is considered a highly complex test for which the highest certificate level would be required. Again, there is no collection code for the vaginal specimen, but you might be able to bill 99000 for the handling. If the Pap smear and culture collection are performed at the same visit, you would only bill 99000 once.

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 When we bill for Pap tests (Q0091), vaginal cultures (87070), and stool guaiac (82270), insurance companies refuse to pay.

They tell me we can collect for obtaining the specimen, but I cannot find the correct CPT codes. How should I proceed?

A It depends on what payer you are billing and whether you have the correct Clinical Laboratories Improvement Act (CLIA) certificate to bill for laboratory procedures.

The code Q0091 was developed by Medicare to reimburse physicians for collecting a Pap smear at the time of an otherwise noncovered service. When they later added the code G0101 for the pelvic and breast exam portion of a preventive visit, they continued to reimburse for the collection as well.

Collection Codes

This collection code is not recognized by all payers, however. In fact, the American College of Obstetricians and Gynecologists (ACOG) has indicated that collection is part of the exam and not a separately billable service. However, some payers will allow you to collect for handling the specimen by using the code 99000.

Lab Codes

As for the lab tests you are billing, all providers are required to have the proper certificate before they can bill for laboratory tests. By billing the lab codes, you are telling the payer you are qualified to perform these tests and that you did, in fact, perform them. Once again, there is no collection code for either of these tests. Code 82270, which is a waived test, can be performed by the physician in the office, and the collection of the stool specimen is an integral part of the code. A waived test, by the way, still requires a certificate (visit www.cms.hhs.gov/clia/certypes.asp for definitions of the various certificate levels).

Culture Codes

The culture code you are using, 87070, is considered a highly complex test for which the highest certificate level would be required. Again, there is no collection code for the vaginal specimen, but you might be able to bill 99000 for the handling. If the Pap smear and culture collection are performed at the same visit, you would only bill 99000 once.

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 When we bill for Pap tests (Q0091), vaginal cultures (87070), and stool guaiac (82270), insurance companies refuse to pay.

They tell me we can collect for obtaining the specimen, but I cannot find the correct CPT codes. How should I proceed?

A It depends on what payer you are billing and whether you have the correct Clinical Laboratories Improvement Act (CLIA) certificate to bill for laboratory procedures.

The code Q0091 was developed by Medicare to reimburse physicians for collecting a Pap smear at the time of an otherwise noncovered service. When they later added the code G0101 for the pelvic and breast exam portion of a preventive visit, they continued to reimburse for the collection as well.

Collection Codes

This collection code is not recognized by all payers, however. In fact, the American College of Obstetricians and Gynecologists (ACOG) has indicated that collection is part of the exam and not a separately billable service. However, some payers will allow you to collect for handling the specimen by using the code 99000.

Lab Codes

As for the lab tests you are billing, all providers are required to have the proper certificate before they can bill for laboratory tests. By billing the lab codes, you are telling the payer you are qualified to perform these tests and that you did, in fact, perform them. Once again, there is no collection code for either of these tests. Code 82270, which is a waived test, can be performed by the physician in the office, and the collection of the stool specimen is an integral part of the code. A waived test, by the way, still requires a certificate (visit www.cms.hhs.gov/clia/certypes.asp for definitions of the various certificate levels).

Culture Codes

The culture code you are using, 87070, is considered a highly complex test for which the highest certificate level would be required. Again, there is no collection code for the vaginal specimen, but you might be able to bill 99000 for the handling. If the Pap smear and culture collection are performed at the same visit, you would only bill 99000 once.

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 When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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 When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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 When do I use the new diagnosis code V72.40 (Pregnancy examination or test, pregnancy unconfirmed)?

A Use V72.40 only when you have not confirmed that the patient is pregnant at the end of the visit. For example: if a blood specimen was drawn and a serum hCG ordered to confirm pregnancy. Since you would not have results before the patient left, V72.40 is appropriate.

If, on the other hand, a urine color test is performed with a positive result, your diagnosis would be V22.0 or V22.1 (supervision of a normal pregnancy). This is per official ICD-9 guidelines stating that you must code what you know at the end of the visit—unless no problem is found, in which case you can code for symptoms or complaints.

Note, however, that when V codes are used, many payers try to bundle the visit at which pregnancy is diagnosed into the global care. If this happens, try using 626.8 (missed period) for the primary diagnosis on the evaluation and management code, and V22.0 or V22.1 for the urine lab test that confirmed pregnancy.

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 When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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 When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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 When we draw estradiol on our fertility patients, we use CPT code 82670 (assay of estradiol). The insurance company changed this to 80415 (chorionic gonadotropin stimulation panel; estradiol response panel), saying it “better represents the services performed.” Is that correct?

A Code 80415 includes a baseline level of estradiol, preferably pooled with 3 samples at 15- to 20-minute intervals. After the baseline is taken, 5,000 U of human chorionic gonadotropin (hCG) are administered intramuscularly. Then, 3 days later, a pooled sampling of estradiol is repeated for response to the evocative agent. This is done to detect ovarian production of estradiol in response to hCG.

If you are not giving hCG to test the response, then the insurer is incorrect and you are right to assign 82670.

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 performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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 performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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 performed 2 dilation and curettage (D&C) procedures with ultrasonic guidance. One was for retained placental fragments; the other, for manual removal of a placenta after elective termination due to severe fetal abnormalities. I am unable to find a code for the ultrasonic guidance to use in addition to the procedure codes—are these services considered inclusive in the surgical procedures? Would I just use 76999 (unlisted ultrasound procedure)?

A While ultrasound guidance is not specifically bundled into the delivery/abortion codes, you cannot count on it being reimbursed separately when done at the time of a D&C. The payer may decide that it is not medically indicated, or that it is routinely performed by the physician in all cases and is thus part of his or her procedure technique. The most appropriate code in this case would be 76986 (ultrasound guidance, intraoperative), rather than the unlisted procedure 76999.

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.

1All vaginal vault suspensions can be coded

The American College of Obstetricians and Gynecologists (ACOG) requested new codes to address the various techniques of vaginal vault suspension. Until this year, only 1 vaginal colpopexy code was available: sacrospinous ligament fixation. For any other type of suspension, we had to bill for the procedure using either the unlisted code 58999 or the code that was closest, 57282 (sacrospinous ligament fixation for prolapse of vagina).

As of January 1, the 2 code revisions, 57282 and 57283, will address any suspension technique (TABLE). Which you choose will depend on whether the suspension occurs outside the peritoneal cavity (by attaching it to the iliococcygeus muscle or sacrospinous ligament), or inside (using the uterosacral ligament or performing a high midline levator myorrhaphy).

Note that the code for the intraperitoneal approach cannot be billed with code 58263 (vaginal hysterectomy with bilateral salpingo-oophorectomy and enterocele repair).

Mesh augmentation

A new code was created for mesh augmentation, when the patient’s tissue is weak or inadequate for cystocele, rectocele, or enterocele repair. Code 57267 is an “add-on” code, meaning it is never used without an additional “base” code. It is billed with 45560 (rectocele repair), 57240 (anterior colporrhaphy), 57250 (posterior colporrhaphy), 57260 (combined anterior and posterior repair), or 57265 (combined anterior and posterior repair with enterocele repair).

Note that the code’s description indicates “each site.” Thus, if mesh is required in both the anterior and posterior compartments, code 57267 is listed twice.

2Cryoablation promoted from “developing technology”

Now rescued from Category III (temporary code 0009T), endometrial cryoablation has its own code, 58356, in the surgery section.

You should not bill separately for endometrial biopsy (58100), dilation and curettage (58120), saline-infusion sonogram/hysterosalpingogram (58340), abdominal ultrasound (76700), or pelvic ultrasound (76856); all are included in 58356. Note that the nomenclature states that ultrasound guidance is also included.

3Less hassle for less-invasive sterilization

Hysteroscopic sterilization (Essure; Conceptus, San Carlos, Calif)—which requires no abdominal incisions and can be performed in an office setting—now has its own code, 58565. Previously, the Healthcare Common Procedure Coding System (HCPCS) code S2555 and the code for an unlisted hysteroscopy (58579) were used to fill this coding gap. Physician practices will be happy to note that this code was given 57.77 relative value units (RVUs) when performed in a nonfacility setting—enough to cover the cost of the implants.

Do not report this with diagnostic hysteroscopy (58555) and/or dilation of cervix (57800). Since the code is valued as a bilateral procedure, add a modifier -52 (reduced services) if the device is placed unilaterally.

4More options for fetal Doppler

The addition of 2 codes for fetal Doppler of the umbilical and middle cerebral arteries (76820 and 76821) is most welcome for maternal-fetal medicine specialists evaluating fetal anemia and fetal growth restriction. Until now, these 2 scans were reported using the Doppler echocardiography codes 76827 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete) or 76828 (Doppler echocardiography, … ; follow-up or repeat study).

 

Still no uterine artery Doppler code

For this, ACOG recommends continuing to use codes 76827 or 76828—but a closer code might be 93976 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study).

Note the slight change in nomenclature for 76827. The phrase “cardiovascular system” was removed for CPT 2005.

ULTRASOUNDNew requirement: Images must be recorded

Most noteworthy of the new ultrasound guidelines is the requirement that an image be recorded. Permanently recorded images with measurements are required for all diagnostic ultrasound examinations (when such measurements are clinically indicated).

Ultrasound guidance procedures also require permanently recorded images of the site to be localized, and a documented description of the localization process, either separately or within the procedure report for which the guidance is utilized. A final, written report should be placed in the patient’s medical record.

For anatomic regions that have “complete” and “limited” ultrasound codes:

• Note the elements that comprise a “complete” exam, and include in the report a description of each or the reason an element could not be visualized.
  
• Use the “limited” code—once per patient exam session—if reporting less than the required elements for a complete exam (eg, limited number of organs or limited portion of region evaluated).
  
• Do not report a “limited” exam for the same exam session as a “complete” exam of that same region.
  

Doppler evaluation of vascular structures (other than color flow used only for anatomic structure identification) is separately reportable.

Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report is not separately reportable.

Nonobstetric ultrasound

When to code complete ultrasound. The code for complete nonobstetric ultrasound (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) encompasses the comprehensive evaluation of the female pelvic anatomy, including:

• measurement of uterus and adnexal structures
  
• measurement of the endometrium
  
• measurement of the bladder (when applicable)
  
• description of any pelvic pathology
  

When to code limited ultrasound. The code for limited nonobstetric ultrasound (76857, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [eg, for follicles]) represents:

• focused examination limited to the assessment of 1 or more elements listed in code 76856, and/or
  
• reevaluation of 1 or more pelvic abnormalities previously seen on ultrasound.
  

Use this code when imaging the urinary bladder alone (not kidneys). If you measure bladder or postvoid residual volume at the same time as the bladder ultrasound, code 51798 (postvoid residual urine and/or bladder capacity by ultrasound, non-imaging) is not added.

ALSO NOTABLETotal omentectomy

Previously, no code existed to describe removal of the uterus and omentum for malignancy without lymph-node dissection. But when omental metastasis is present, pelvic and paraaortic lymph node dissection for staging is not usually necessary, since the disease has already spread into the abdominal cavity. New code 58956 addresses this problem. To report this code, the documentation must clearly indicate a total omentectomy (removal of both the lesser and greater omentum, also referred to as a supracolic omentectomy).

Debridement of genitalia

Three codes address debridement of the external genitalia and perineum skin for necrotizing soft tissue infection.

Screening for chromosome abnormalities

A new laboratory services code, 84163, describes the pregnancy-associated plasma protein-A (PAPP-A) screening test, used to identify women at highest risk of carrying a fetus with Down Syndrome, trisomy 18, or other chromosomal abnormality.

Oocyte storage

A revision to make “oocyte” plural in code 89346 (storage [per year]; oocytes) clarifies that each oocyte stored is not coded separately.

New appendices

Appendix F lists codes exempt from modifier -63 (Procedure performed on infants less than 4 kg).

Appendix G lists procedures that include conscious sedation. A new symbol, ••, was created to denote this for the individual codes included in this section. The only Ob/Gyn-specific code that carries this symbol is 58823 (drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [eg, ovarian, pericolic]).

Appendix H is an alphabetic index of Category II code performance measures (the index lists them by clinical condition or topic), and includes a brief description of the performance measure and its source.

Appendix I lists genetic testing code modifiers. Report these with the molecular lab procedures related to genetic testing. The modifiers are categorized by mutation: The first digit indicates the disease category, the second denotes the gene type. For instance, 0A signifies testing for the BRCA1 gene.

1All vaginal vault suspensions can be coded

The American College of Obstetricians and Gynecologists (ACOG) requested new codes to address the various techniques of vaginal vault suspension. Until this year, only 1 vaginal colpopexy code was available: sacrospinous ligament fixation. For any other type of suspension, we had to bill for the procedure using either the unlisted code 58999 or the code that was closest, 57282 (sacrospinous ligament fixation for prolapse of vagina).

As of January 1, the 2 code revisions, 57282 and 57283, will address any suspension technique (TABLE). Which you choose will depend on whether the suspension occurs outside the peritoneal cavity (by attaching it to the iliococcygeus muscle or sacrospinous ligament), or inside (using the uterosacral ligament or performing a high midline levator myorrhaphy).

Note that the code for the intraperitoneal approach cannot be billed with code 58263 (vaginal hysterectomy with bilateral salpingo-oophorectomy and enterocele repair).

Mesh augmentation

A new code was created for mesh augmentation, when the patient’s tissue is weak or inadequate for cystocele, rectocele, or enterocele repair. Code 57267 is an “add-on” code, meaning it is never used without an additional “base” code. It is billed with 45560 (rectocele repair), 57240 (anterior colporrhaphy), 57250 (posterior colporrhaphy), 57260 (combined anterior and posterior repair), or 57265 (combined anterior and posterior repair with enterocele repair).

Note that the code’s description indicates “each site.” Thus, if mesh is required in both the anterior and posterior compartments, code 57267 is listed twice.

2Cryoablation promoted from “developing technology”

Now rescued from Category III (temporary code 0009T), endometrial cryoablation has its own code, 58356, in the surgery section.

You should not bill separately for endometrial biopsy (58100), dilation and curettage (58120), saline-infusion sonogram/hysterosalpingogram (58340), abdominal ultrasound (76700), or pelvic ultrasound (76856); all are included in 58356. Note that the nomenclature states that ultrasound guidance is also included.

3Less hassle for less-invasive sterilization

Hysteroscopic sterilization (Essure; Conceptus, San Carlos, Calif)—which requires no abdominal incisions and can be performed in an office setting—now has its own code, 58565. Previously, the Healthcare Common Procedure Coding System (HCPCS) code S2555 and the code for an unlisted hysteroscopy (58579) were used to fill this coding gap. Physician practices will be happy to note that this code was given 57.77 relative value units (RVUs) when performed in a nonfacility setting—enough to cover the cost of the implants.

Do not report this with diagnostic hysteroscopy (58555) and/or dilation of cervix (57800). Since the code is valued as a bilateral procedure, add a modifier -52 (reduced services) if the device is placed unilaterally.

4More options for fetal Doppler

The addition of 2 codes for fetal Doppler of the umbilical and middle cerebral arteries (76820 and 76821) is most welcome for maternal-fetal medicine specialists evaluating fetal anemia and fetal growth restriction. Until now, these 2 scans were reported using the Doppler echocardiography codes 76827 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete) or 76828 (Doppler echocardiography, … ; follow-up or repeat study).

 

Still no uterine artery Doppler code

For this, ACOG recommends continuing to use codes 76827 or 76828—but a closer code might be 93976 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study).

Note the slight change in nomenclature for 76827. The phrase “cardiovascular system” was removed for CPT 2005.

ULTRASOUNDNew requirement: Images must be recorded

Most noteworthy of the new ultrasound guidelines is the requirement that an image be recorded. Permanently recorded images with measurements are required for all diagnostic ultrasound examinations (when such measurements are clinically indicated).

Ultrasound guidance procedures also require permanently recorded images of the site to be localized, and a documented description of the localization process, either separately or within the procedure report for which the guidance is utilized. A final, written report should be placed in the patient’s medical record.

For anatomic regions that have “complete” and “limited” ultrasound codes:

• Note the elements that comprise a “complete” exam, and include in the report a description of each or the reason an element could not be visualized.
  
• Use the “limited” code—once per patient exam session—if reporting less than the required elements for a complete exam (eg, limited number of organs or limited portion of region evaluated).
  
• Do not report a “limited” exam for the same exam session as a “complete” exam of that same region.
  

Doppler evaluation of vascular structures (other than color flow used only for anatomic structure identification) is separately reportable.

Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report is not separately reportable.

Nonobstetric ultrasound

When to code complete ultrasound. The code for complete nonobstetric ultrasound (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) encompasses the comprehensive evaluation of the female pelvic anatomy, including:

• measurement of uterus and adnexal structures
  
• measurement of the endometrium
  
• measurement of the bladder (when applicable)
  
• description of any pelvic pathology
  

When to code limited ultrasound. The code for limited nonobstetric ultrasound (76857, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [eg, for follicles]) represents:

• focused examination limited to the assessment of 1 or more elements listed in code 76856, and/or
  
• reevaluation of 1 or more pelvic abnormalities previously seen on ultrasound.
  

Use this code when imaging the urinary bladder alone (not kidneys). If you measure bladder or postvoid residual volume at the same time as the bladder ultrasound, code 51798 (postvoid residual urine and/or bladder capacity by ultrasound, non-imaging) is not added.

ALSO NOTABLETotal omentectomy

Previously, no code existed to describe removal of the uterus and omentum for malignancy without lymph-node dissection. But when omental metastasis is present, pelvic and paraaortic lymph node dissection for staging is not usually necessary, since the disease has already spread into the abdominal cavity. New code 58956 addresses this problem. To report this code, the documentation must clearly indicate a total omentectomy (removal of both the lesser and greater omentum, also referred to as a supracolic omentectomy).

Debridement of genitalia

Three codes address debridement of the external genitalia and perineum skin for necrotizing soft tissue infection.

Screening for chromosome abnormalities

A new laboratory services code, 84163, describes the pregnancy-associated plasma protein-A (PAPP-A) screening test, used to identify women at highest risk of carrying a fetus with Down Syndrome, trisomy 18, or other chromosomal abnormality.

Oocyte storage

A revision to make “oocyte” plural in code 89346 (storage [per year]; oocytes) clarifies that each oocyte stored is not coded separately.

New appendices

Appendix F lists codes exempt from modifier -63 (Procedure performed on infants less than 4 kg).

Appendix G lists procedures that include conscious sedation. A new symbol, ••, was created to denote this for the individual codes included in this section. The only Ob/Gyn-specific code that carries this symbol is 58823 (drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [eg, ovarian, pericolic]).

Appendix H is an alphabetic index of Category II code performance measures (the index lists them by clinical condition or topic), and includes a brief description of the performance measure and its source.

Appendix I lists genetic testing code modifiers. Report these with the molecular lab procedures related to genetic testing. The modifiers are categorized by mutation: The first digit indicates the disease category, the second denotes the gene type. For instance, 0A signifies testing for the BRCA1 gene.

1All vaginal vault suspensions can be coded

The American College of Obstetricians and Gynecologists (ACOG) requested new codes to address the various techniques of vaginal vault suspension. Until this year, only 1 vaginal colpopexy code was available: sacrospinous ligament fixation. For any other type of suspension, we had to bill for the procedure using either the unlisted code 58999 or the code that was closest, 57282 (sacrospinous ligament fixation for prolapse of vagina).

As of January 1, the 2 code revisions, 57282 and 57283, will address any suspension technique (TABLE). Which you choose will depend on whether the suspension occurs outside the peritoneal cavity (by attaching it to the iliococcygeus muscle or sacrospinous ligament), or inside (using the uterosacral ligament or performing a high midline levator myorrhaphy).

Note that the code for the intraperitoneal approach cannot be billed with code 58263 (vaginal hysterectomy with bilateral salpingo-oophorectomy and enterocele repair).

Mesh augmentation

A new code was created for mesh augmentation, when the patient’s tissue is weak or inadequate for cystocele, rectocele, or enterocele repair. Code 57267 is an “add-on” code, meaning it is never used without an additional “base” code. It is billed with 45560 (rectocele repair), 57240 (anterior colporrhaphy), 57250 (posterior colporrhaphy), 57260 (combined anterior and posterior repair), or 57265 (combined anterior and posterior repair with enterocele repair).

Note that the code’s description indicates “each site.” Thus, if mesh is required in both the anterior and posterior compartments, code 57267 is listed twice.

2Cryoablation promoted from “developing technology”

Now rescued from Category III (temporary code 0009T), endometrial cryoablation has its own code, 58356, in the surgery section.

You should not bill separately for endometrial biopsy (58100), dilation and curettage (58120), saline-infusion sonogram/hysterosalpingogram (58340), abdominal ultrasound (76700), or pelvic ultrasound (76856); all are included in 58356. Note that the nomenclature states that ultrasound guidance is also included.

3Less hassle for less-invasive sterilization

Hysteroscopic sterilization (Essure; Conceptus, San Carlos, Calif)—which requires no abdominal incisions and can be performed in an office setting—now has its own code, 58565. Previously, the Healthcare Common Procedure Coding System (HCPCS) code S2555 and the code for an unlisted hysteroscopy (58579) were used to fill this coding gap. Physician practices will be happy to note that this code was given 57.77 relative value units (RVUs) when performed in a nonfacility setting—enough to cover the cost of the implants.

Do not report this with diagnostic hysteroscopy (58555) and/or dilation of cervix (57800). Since the code is valued as a bilateral procedure, add a modifier -52 (reduced services) if the device is placed unilaterally.

4More options for fetal Doppler

The addition of 2 codes for fetal Doppler of the umbilical and middle cerebral arteries (76820 and 76821) is most welcome for maternal-fetal medicine specialists evaluating fetal anemia and fetal growth restriction. Until now, these 2 scans were reported using the Doppler echocardiography codes 76827 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete) or 76828 (Doppler echocardiography, … ; follow-up or repeat study).

 

Still no uterine artery Doppler code

For this, ACOG recommends continuing to use codes 76827 or 76828—but a closer code might be 93976 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study).

Note the slight change in nomenclature for 76827. The phrase “cardiovascular system” was removed for CPT 2005.

ULTRASOUNDNew requirement: Images must be recorded

Most noteworthy of the new ultrasound guidelines is the requirement that an image be recorded. Permanently recorded images with measurements are required for all diagnostic ultrasound examinations (when such measurements are clinically indicated).

Ultrasound guidance procedures also require permanently recorded images of the site to be localized, and a documented description of the localization process, either separately or within the procedure report for which the guidance is utilized. A final, written report should be placed in the patient’s medical record.

For anatomic regions that have “complete” and “limited” ultrasound codes:

• Note the elements that comprise a “complete” exam, and include in the report a description of each or the reason an element could not be visualized.
  
• Use the “limited” code—once per patient exam session—if reporting less than the required elements for a complete exam (eg, limited number of organs or limited portion of region evaluated).
  
• Do not report a “limited” exam for the same exam session as a “complete” exam of that same region.
  

Doppler evaluation of vascular structures (other than color flow used only for anatomic structure identification) is separately reportable.

Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report is not separately reportable.

Nonobstetric ultrasound

When to code complete ultrasound. The code for complete nonobstetric ultrasound (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) encompasses the comprehensive evaluation of the female pelvic anatomy, including:

• measurement of uterus and adnexal structures
  
• measurement of the endometrium
  
• measurement of the bladder (when applicable)
  
• description of any pelvic pathology
  

When to code limited ultrasound. The code for limited nonobstetric ultrasound (76857, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [eg, for follicles]) represents:

• focused examination limited to the assessment of 1 or more elements listed in code 76856, and/or
  
• reevaluation of 1 or more pelvic abnormalities previously seen on ultrasound.
  

Use this code when imaging the urinary bladder alone (not kidneys). If you measure bladder or postvoid residual volume at the same time as the bladder ultrasound, code 51798 (postvoid residual urine and/or bladder capacity by ultrasound, non-imaging) is not added.

ALSO NOTABLETotal omentectomy

Previously, no code existed to describe removal of the uterus and omentum for malignancy without lymph-node dissection. But when omental metastasis is present, pelvic and paraaortic lymph node dissection for staging is not usually necessary, since the disease has already spread into the abdominal cavity. New code 58956 addresses this problem. To report this code, the documentation must clearly indicate a total omentectomy (removal of both the lesser and greater omentum, also referred to as a supracolic omentectomy).

Debridement of genitalia

Three codes address debridement of the external genitalia and perineum skin for necrotizing soft tissue infection.

Screening for chromosome abnormalities

A new laboratory services code, 84163, describes the pregnancy-associated plasma protein-A (PAPP-A) screening test, used to identify women at highest risk of carrying a fetus with Down Syndrome, trisomy 18, or other chromosomal abnormality.

Oocyte storage

A revision to make “oocyte” plural in code 89346 (storage [per year]; oocytes) clarifies that each oocyte stored is not coded separately.

New appendices

Appendix F lists codes exempt from modifier -63 (Procedure performed on infants less than 4 kg).

Appendix G lists procedures that include conscious sedation. A new symbol, ••, was created to denote this for the individual codes included in this section. The only Ob/Gyn-specific code that carries this symbol is 58823 (drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous [eg, ovarian, pericolic]).

Appendix H is an alphabetic index of Category II code performance measures (the index lists them by clinical condition or topic), and includes a brief description of the performance measure and its source.

Appendix I lists genetic testing code modifiers. Report these with the molecular lab procedures related to genetic testing. The modifiers are categorized by mutation: The first digit indicates the disease category, the second denotes the gene type. For instance, 0A signifies testing for the BRCA1 gene.

Mrs. Smith undergoes a screening Pap smear at her annual exam. It has been several years since her last Pap test. The report indicates atypical glandular cells, favor neoplastic. You ask her to return for further testing. The coding dilemma: Should you report this as cancer in situ (233.1) or atypical cells of undetermined significance “favor dysplasia” (795.02)?

Thanks to the newly revised Pap smear section of the International Classification of Diseases–9th Revision–Clinical Modification (ICD-9-CM), frustrating scenarios like the one above are now a thing of the past.

The updated Pap codes are the most welcome changes to ICD-9 for 2005, but they’re not the only revisions that will ease coding difficulties in the coming year. A clip-and-save chart details the changes most relevant to Ob/Gyn practice.

Reporting Pap smear results

The ambiguous nature of Pap smear coding in recent years stemmed from some unfortunate timing: In October 2001, the codes for abnormal Pap smear (795.0X) were revised to correspond to Bethesda system findings, reported by more than 90% of US laboratories. Just before this revision was implemented, however, the Bethesda Committee revised its terminology, so the new codes no longer matched.

The codes now reflect the hierarchy of conditions as described by Bethesda. Thus, reference to “favor benign” and “favor dysplasia” were removed.

Category 795 was changed to “Other and nonspecific abnormal cytological, histological, immunological and DNA test findings.” Next, the heading for code 795.0 was changed to allow coding for both an abnormal Pap smear and cervical human papillomavirus (HPV).

New codes were added to report findings of a high-grade squamous intraepithelial lesion (HGSIL) and low-grade squamous intraepithelial lesion (LGSIL), and to differentiate between these results from a Pap smear specimen and histologic confirmation of dysplasia from a tissue biopsy.

A few notes:

• Glandular cell changes are now coded to 795.00. This includes a “favor neoplastic” finding, which solves the dilemma posed by the case example.
  
• Unsatisfactory or inadequate smear, previously coded with 795.09, is now 795.08.
  
• Code 795.09 is now used when a DNA test indicates a low risk for HPV (HPV types 6 and 11)
  
• When reporting 795.05 or 795.09, use an additional code for the associated HPV (079.4).
  

Why these revisions were crucial. Without a code for “atypical squamous cells–cannot rule out high-grade squamous intraepithelial lesions” (ASC-H) versus “atypical squamous cells–undetermined significance” (ASC-US), it was difficult to establish the medical need for HPV tests. The American Society for Colposcopy and Cervical Pathology recommends HPV testing for ASC-US, but not for ASC-H, which should proceed to follow-up colposcopy.

The revision also clarifies that category 795 diagnostic codes are not used for cervical intraepithelial neoplasia (CIN) or dysplasia pathology results.

CIN or dysplasia

For tissue biopsy pathology results indicating CIN 3 or severe dysplasia of the cervix, use code 233.1. For CIN 1 or 2 or mild to moderate dysplasia, use one of the expanded dysplasia codes from the 622.1 series.

Remember: The dysplasia codes are reported as a result of histologic confirmation; codes 795.00 to 795.09 involve a cytologic examination only.

Genital prolapse: more detail on the cause

Previously, code 618.0 covered a range of conditions, from cystocele to vaginal prolapse. However, since CPT is more specific about the various prolapse-repair procedures, ACOG requested an expansion of this code to provide additional detail.

Note, also, that a new code for overflow incontinence, 788.38, was added.

Female genital mutilation

A new subcategory—629.2, female genital mutilation (FGM) status—includes codes representing the range of FGM procedures, from partial clitoris amputation to the procedure known as infibulation.

Use these codes for a primary diagnosis in a nonpregnant patient seeking treatment to correct the mutilation, or as a secondary diagnosis when the patient is currently pregnant, or to medically justify cesarean delivery or a complicated vaginal delivery.

Endometrial hyperplasia

Code 621.3, previously used to report endometrial cystic hyperplasia, has been expanded to 4 new codes.

Peripartum cardiomyopathy

Code 648.6X (other cardiovascular diseases) now specifically excludes peripartum cardiomyopathy, which is coded 674.5X.

Diabetes mellitus

Diabetes is no longer termed insulin-dependent and non–insulin-dependent, but rather type I or type II (differentiated by the functioning of pancreatic beta cells, not by insulin use). Thus, the fifth-digit subclassification used with the diabetes codes in category 250 was revised as follows:

• 0–type II or unspecified type, not stated as uncontrolled
  
• 1–type I (juvenile type), not stated as uncontrolled
  
• 2–type II or unspecified type, uncontrolled
  
• 3–type I (juvenile type), uncontrolled
  

 

Report fifth-digits 0 and 2 even if the patient requires insulin—in which case, you may also report the new code V58.67 (long-term current use of insulin). This can be used as a secondary diagnosis, or as a primary diagnosis when the patient is seen for possible long-term effects rather than diabetic control. (Long-term current use of aspirin was also given a code, V58.66.)

V code changes Gynecologic exam

Per ACOG’s request, V72.3 has been expanded into 2 codes:

V72.31 covers routine gynecologic examination—including a Pap smear, if performed. Thus, do not report V76.2 (special screening for malignant neoplasms, cervix) with V72.31 for the exam. Note, however, that if the patient’s cervix is absent and a vaginal Pap smear is collected at the time of the visit, code V76.47 (routine vaginal Pap smear) is also needed.

V72.32 describes a repeat Pap smear in the following scenario: A patient has an abnormal Pap test and is brought back 3 months later for a follow-up Pap. (The diagnosis for that visit is the abnormal result.) The results come back normal and she is asked to return in a few months. You will use V72.32 for this last encounter.

ACOG clarifies V72.32 may be used more than once at the physician’s discretion, since the usual protocol is to perform more frequent Pap smears until obtaining 3 consecutive negative results. Caveat: Check with your Medicare carrier before using this code for the repeat Pap smears.

Pregnancy tests

With the expansion of V72.4, ICD-9 now has an option for a pregnancy test done prior to a procedure that may harm a fetus, or simply because you suspect pregnancy:

Use V72.40 when you perform a pregnancy test, but have not determined whether the patient is pregnant by the end of the visit (ie, a blood rather than urine test). Note that if the pregnancy test is positive, also report code V22.X, per ICD-9 guidelines. This pregnancy diagnosis can be linked to the CPT pregnancy test code.

Use V72.41 if you confirm she is not pregnant during this visit. (Again, if the test is positive, use code V22.X.)

Hormone replacement therapy

The term “postmenopausal” was moved to a parenthetical note for code V07.4, to denote that this code should be reported anytime a woman is placed on estrogen replacement therapy. ICD-9 also has clarified that it is not appropriate to use V58.69 (long-term [current] use of other high-risk medications) for patients on hormone replacement therapy—instead, select code V07.4.

Screening for osteoporosis

ICD-9 has clarified that code V07.4 should be reported with the code for osteoporosis screening (V82.81), if applicable.

Genetic susceptibility to disease

A new category addresses prophylactic organ removal. Until now, ICD-9 had codes to indicate that an encounter was for organ removal, but not to describe the reason for the removal.

Further, these codes were needed because the “carrier status” codes can be used only when the patient is a disease carrier, able to pass it to offspring—not when she herself is at risk.

Note that before you can use these codes, the patient’s record should show an abnormal gene confirmed by genetic test.

Acquired absence of organ

ICD-9 has clarified that code V45.77 (acquired absence of genital organs), excludes the new FGM status codes (629.20 to 629.23).

Exposure to communicable diseases

The American Academy of Pediatrics requested the addition of exposure codes to viral and other communicable diseases. Most important to Ob/Gyns is exposure to chickenpox (varicella), if the mother was not previously exposed. This new code, V01.71, may be enough to support the medical necessity for laboratory work to test for immunity to chickenpox.

Report code V01.79 for exposure to other viral diseases.

Lack of adequate sleep

New code V69.4 is reported for sleep deprivation, but excludes insomnia.

Mrs. Smith undergoes a screening Pap smear at her annual exam. It has been several years since her last Pap test. The report indicates atypical glandular cells, favor neoplastic. You ask her to return for further testing. The coding dilemma: Should you report this as cancer in situ (233.1) or atypical cells of undetermined significance “favor dysplasia” (795.02)?

Thanks to the newly revised Pap smear section of the International Classification of Diseases–9th Revision–Clinical Modification (ICD-9-CM), frustrating scenarios like the one above are now a thing of the past.

The updated Pap codes are the most welcome changes to ICD-9 for 2005, but they’re not the only revisions that will ease coding difficulties in the coming year. A clip-and-save chart details the changes most relevant to Ob/Gyn practice.

Reporting Pap smear results

The ambiguous nature of Pap smear coding in recent years stemmed from some unfortunate timing: In October 2001, the codes for abnormal Pap smear (795.0X) were revised to correspond to Bethesda system findings, reported by more than 90% of US laboratories. Just before this revision was implemented, however, the Bethesda Committee revised its terminology, so the new codes no longer matched.

The codes now reflect the hierarchy of conditions as described by Bethesda. Thus, reference to “favor benign” and “favor dysplasia” were removed.

Category 795 was changed to “Other and nonspecific abnormal cytological, histological, immunological and DNA test findings.” Next, the heading for code 795.0 was changed to allow coding for both an abnormal Pap smear and cervical human papillomavirus (HPV).

New codes were added to report findings of a high-grade squamous intraepithelial lesion (HGSIL) and low-grade squamous intraepithelial lesion (LGSIL), and to differentiate between these results from a Pap smear specimen and histologic confirmation of dysplasia from a tissue biopsy.

A few notes:

• Glandular cell changes are now coded to 795.00. This includes a “favor neoplastic” finding, which solves the dilemma posed by the case example.
  
• Unsatisfactory or inadequate smear, previously coded with 795.09, is now 795.08.
  
• Code 795.09 is now used when a DNA test indicates a low risk for HPV (HPV types 6 and 11)
  
• When reporting 795.05 or 795.09, use an additional code for the associated HPV (079.4).
  

Why these revisions were crucial. Without a code for “atypical squamous cells–cannot rule out high-grade squamous intraepithelial lesions” (ASC-H) versus “atypical squamous cells–undetermined significance” (ASC-US), it was difficult to establish the medical need for HPV tests. The American Society for Colposcopy and Cervical Pathology recommends HPV testing for ASC-US, but not for ASC-H, which should proceed to follow-up colposcopy.

The revision also clarifies that category 795 diagnostic codes are not used for cervical intraepithelial neoplasia (CIN) or dysplasia pathology results.

CIN or dysplasia

For tissue biopsy pathology results indicating CIN 3 or severe dysplasia of the cervix, use code 233.1. For CIN 1 or 2 or mild to moderate dysplasia, use one of the expanded dysplasia codes from the 622.1 series.

Remember: The dysplasia codes are reported as a result of histologic confirmation; codes 795.00 to 795.09 involve a cytologic examination only.

Genital prolapse: more detail on the cause

Previously, code 618.0 covered a range of conditions, from cystocele to vaginal prolapse. However, since CPT is more specific about the various prolapse-repair procedures, ACOG requested an expansion of this code to provide additional detail.

Note, also, that a new code for overflow incontinence, 788.38, was added.

Female genital mutilation

A new subcategory—629.2, female genital mutilation (FGM) status—includes codes representing the range of FGM procedures, from partial clitoris amputation to the procedure known as infibulation.

Use these codes for a primary diagnosis in a nonpregnant patient seeking treatment to correct the mutilation, or as a secondary diagnosis when the patient is currently pregnant, or to medically justify cesarean delivery or a complicated vaginal delivery.

Endometrial hyperplasia

Code 621.3, previously used to report endometrial cystic hyperplasia, has been expanded to 4 new codes.

Peripartum cardiomyopathy

Code 648.6X (other cardiovascular diseases) now specifically excludes peripartum cardiomyopathy, which is coded 674.5X.

Diabetes mellitus

Diabetes is no longer termed insulin-dependent and non–insulin-dependent, but rather type I or type II (differentiated by the functioning of pancreatic beta cells, not by insulin use). Thus, the fifth-digit subclassification used with the diabetes codes in category 250 was revised as follows:

• 0–type II or unspecified type, not stated as uncontrolled
  
• 1–type I (juvenile type), not stated as uncontrolled
  
• 2–type II or unspecified type, uncontrolled
  
• 3–type I (juvenile type), uncontrolled
  

 

Report fifth-digits 0 and 2 even if the patient requires insulin—in which case, you may also report the new code V58.67 (long-term current use of insulin). This can be used as a secondary diagnosis, or as a primary diagnosis when the patient is seen for possible long-term effects rather than diabetic control. (Long-term current use of aspirin was also given a code, V58.66.)

V code changes Gynecologic exam

Per ACOG’s request, V72.3 has been expanded into 2 codes:

V72.31 covers routine gynecologic examination—including a Pap smear, if performed. Thus, do not report V76.2 (special screening for malignant neoplasms, cervix) with V72.31 for the exam. Note, however, that if the patient’s cervix is absent and a vaginal Pap smear is collected at the time of the visit, code V76.47 (routine vaginal Pap smear) is also needed.

V72.32 describes a repeat Pap smear in the following scenario: A patient has an abnormal Pap test and is brought back 3 months later for a follow-up Pap. (The diagnosis for that visit is the abnormal result.) The results come back normal and she is asked to return in a few months. You will use V72.32 for this last encounter.

ACOG clarifies V72.32 may be used more than once at the physician’s discretion, since the usual protocol is to perform more frequent Pap smears until obtaining 3 consecutive negative results. Caveat: Check with your Medicare carrier before using this code for the repeat Pap smears.

Pregnancy tests

With the expansion of V72.4, ICD-9 now has an option for a pregnancy test done prior to a procedure that may harm a fetus, or simply because you suspect pregnancy:

Use V72.40 when you perform a pregnancy test, but have not determined whether the patient is pregnant by the end of the visit (ie, a blood rather than urine test). Note that if the pregnancy test is positive, also report code V22.X, per ICD-9 guidelines. This pregnancy diagnosis can be linked to the CPT pregnancy test code.

Use V72.41 if you confirm she is not pregnant during this visit. (Again, if the test is positive, use code V22.X.)

Hormone replacement therapy

The term “postmenopausal” was moved to a parenthetical note for code V07.4, to denote that this code should be reported anytime a woman is placed on estrogen replacement therapy. ICD-9 also has clarified that it is not appropriate to use V58.69 (long-term [current] use of other high-risk medications) for patients on hormone replacement therapy—instead, select code V07.4.

Screening for osteoporosis

ICD-9 has clarified that code V07.4 should be reported with the code for osteoporosis screening (V82.81), if applicable.

Genetic susceptibility to disease

A new category addresses prophylactic organ removal. Until now, ICD-9 had codes to indicate that an encounter was for organ removal, but not to describe the reason for the removal.

Further, these codes were needed because the “carrier status” codes can be used only when the patient is a disease carrier, able to pass it to offspring—not when she herself is at risk.

Note that before you can use these codes, the patient’s record should show an abnormal gene confirmed by genetic test.

Acquired absence of organ

ICD-9 has clarified that code V45.77 (acquired absence of genital organs), excludes the new FGM status codes (629.20 to 629.23).

Exposure to communicable diseases

The American Academy of Pediatrics requested the addition of exposure codes to viral and other communicable diseases. Most important to Ob/Gyns is exposure to chickenpox (varicella), if the mother was not previously exposed. This new code, V01.71, may be enough to support the medical necessity for laboratory work to test for immunity to chickenpox.

Report code V01.79 for exposure to other viral diseases.

Lack of adequate sleep

New code V69.4 is reported for sleep deprivation, but excludes insomnia.

Mrs. Smith undergoes a screening Pap smear at her annual exam. It has been several years since her last Pap test. The report indicates atypical glandular cells, favor neoplastic. You ask her to return for further testing. The coding dilemma: Should you report this as cancer in situ (233.1) or atypical cells of undetermined significance “favor dysplasia” (795.02)?

Thanks to the newly revised Pap smear section of the International Classification of Diseases–9th Revision–Clinical Modification (ICD-9-CM), frustrating scenarios like the one above are now a thing of the past.

The updated Pap codes are the most welcome changes to ICD-9 for 2005, but they’re not the only revisions that will ease coding difficulties in the coming year. A clip-and-save chart details the changes most relevant to Ob/Gyn practice.

Reporting Pap smear results

The ambiguous nature of Pap smear coding in recent years stemmed from some unfortunate timing: In October 2001, the codes for abnormal Pap smear (795.0X) were revised to correspond to Bethesda system findings, reported by more than 90% of US laboratories. Just before this revision was implemented, however, the Bethesda Committee revised its terminology, so the new codes no longer matched.

The codes now reflect the hierarchy of conditions as described by Bethesda. Thus, reference to “favor benign” and “favor dysplasia” were removed.

Category 795 was changed to “Other and nonspecific abnormal cytological, histological, immunological and DNA test findings.” Next, the heading for code 795.0 was changed to allow coding for both an abnormal Pap smear and cervical human papillomavirus (HPV).

New codes were added to report findings of a high-grade squamous intraepithelial lesion (HGSIL) and low-grade squamous intraepithelial lesion (LGSIL), and to differentiate between these results from a Pap smear specimen and histologic confirmation of dysplasia from a tissue biopsy.

A few notes:

• Glandular cell changes are now coded to 795.00. This includes a “favor neoplastic” finding, which solves the dilemma posed by the case example.
  
• Unsatisfactory or inadequate smear, previously coded with 795.09, is now 795.08.
  
• Code 795.09 is now used when a DNA test indicates a low risk for HPV (HPV types 6 and 11)
  
• When reporting 795.05 or 795.09, use an additional code for the associated HPV (079.4).
  

Why these revisions were crucial. Without a code for “atypical squamous cells–cannot rule out high-grade squamous intraepithelial lesions” (ASC-H) versus “atypical squamous cells–undetermined significance” (ASC-US), it was difficult to establish the medical need for HPV tests. The American Society for Colposcopy and Cervical Pathology recommends HPV testing for ASC-US, but not for ASC-H, which should proceed to follow-up colposcopy.

The revision also clarifies that category 795 diagnostic codes are not used for cervical intraepithelial neoplasia (CIN) or dysplasia pathology results.

CIN or dysplasia

For tissue biopsy pathology results indicating CIN 3 or severe dysplasia of the cervix, use code 233.1. For CIN 1 or 2 or mild to moderate dysplasia, use one of the expanded dysplasia codes from the 622.1 series.

Remember: The dysplasia codes are reported as a result of histologic confirmation; codes 795.00 to 795.09 involve a cytologic examination only.

Genital prolapse: more detail on the cause

Previously, code 618.0 covered a range of conditions, from cystocele to vaginal prolapse. However, since CPT is more specific about the various prolapse-repair procedures, ACOG requested an expansion of this code to provide additional detail.

Note, also, that a new code for overflow incontinence, 788.38, was added.

Female genital mutilation

A new subcategory—629.2, female genital mutilation (FGM) status—includes codes representing the range of FGM procedures, from partial clitoris amputation to the procedure known as infibulation.

Use these codes for a primary diagnosis in a nonpregnant patient seeking treatment to correct the mutilation, or as a secondary diagnosis when the patient is currently pregnant, or to medically justify cesarean delivery or a complicated vaginal delivery.

Endometrial hyperplasia

Code 621.3, previously used to report endometrial cystic hyperplasia, has been expanded to 4 new codes.

Peripartum cardiomyopathy

Code 648.6X (other cardiovascular diseases) now specifically excludes peripartum cardiomyopathy, which is coded 674.5X.

Diabetes mellitus

Diabetes is no longer termed insulin-dependent and non–insulin-dependent, but rather type I or type II (differentiated by the functioning of pancreatic beta cells, not by insulin use). Thus, the fifth-digit subclassification used with the diabetes codes in category 250 was revised as follows:

• 0–type II or unspecified type, not stated as uncontrolled
  
• 1–type I (juvenile type), not stated as uncontrolled
  
• 2–type II or unspecified type, uncontrolled
  
• 3–type I (juvenile type), uncontrolled
  

 

Report fifth-digits 0 and 2 even if the patient requires insulin—in which case, you may also report the new code V58.67 (long-term current use of insulin). This can be used as a secondary diagnosis, or as a primary diagnosis when the patient is seen for possible long-term effects rather than diabetic control. (Long-term current use of aspirin was also given a code, V58.66.)

V code changes Gynecologic exam

Per ACOG’s request, V72.3 has been expanded into 2 codes:

V72.31 covers routine gynecologic examination—including a Pap smear, if performed. Thus, do not report V76.2 (special screening for malignant neoplasms, cervix) with V72.31 for the exam. Note, however, that if the patient’s cervix is absent and a vaginal Pap smear is collected at the time of the visit, code V76.47 (routine vaginal Pap smear) is also needed.

V72.32 describes a repeat Pap smear in the following scenario: A patient has an abnormal Pap test and is brought back 3 months later for a follow-up Pap. (The diagnosis for that visit is the abnormal result.) The results come back normal and she is asked to return in a few months. You will use V72.32 for this last encounter.

ACOG clarifies V72.32 may be used more than once at the physician’s discretion, since the usual protocol is to perform more frequent Pap smears until obtaining 3 consecutive negative results. Caveat: Check with your Medicare carrier before using this code for the repeat Pap smears.

Pregnancy tests

With the expansion of V72.4, ICD-9 now has an option for a pregnancy test done prior to a procedure that may harm a fetus, or simply because you suspect pregnancy:

Use V72.40 when you perform a pregnancy test, but have not determined whether the patient is pregnant by the end of the visit (ie, a blood rather than urine test). Note that if the pregnancy test is positive, also report code V22.X, per ICD-9 guidelines. This pregnancy diagnosis can be linked to the CPT pregnancy test code.

Use V72.41 if you confirm she is not pregnant during this visit. (Again, if the test is positive, use code V22.X.)

Hormone replacement therapy

The term “postmenopausal” was moved to a parenthetical note for code V07.4, to denote that this code should be reported anytime a woman is placed on estrogen replacement therapy. ICD-9 also has clarified that it is not appropriate to use V58.69 (long-term [current] use of other high-risk medications) for patients on hormone replacement therapy—instead, select code V07.4.

Screening for osteoporosis

ICD-9 has clarified that code V07.4 should be reported with the code for osteoporosis screening (V82.81), if applicable.

Genetic susceptibility to disease

A new category addresses prophylactic organ removal. Until now, ICD-9 had codes to indicate that an encounter was for organ removal, but not to describe the reason for the removal.

Further, these codes were needed because the “carrier status” codes can be used only when the patient is a disease carrier, able to pass it to offspring—not when she herself is at risk.

Note that before you can use these codes, the patient’s record should show an abnormal gene confirmed by genetic test.

Acquired absence of organ

ICD-9 has clarified that code V45.77 (acquired absence of genital organs), excludes the new FGM status codes (629.20 to 629.23).

Exposure to communicable diseases

The American Academy of Pediatrics requested the addition of exposure codes to viral and other communicable diseases. Most important to Ob/Gyns is exposure to chickenpox (varicella), if the mother was not previously exposed. This new code, V01.71, may be enough to support the medical necessity for laboratory work to test for immunity to chickenpox.

Report code V01.79 for exposure to other viral diseases.

Lack of adequate sleep

New code V69.4 is reported for sleep deprivation, but excludes insomnia.

Q I performed surgical treatment for torsion of the ovary using the following procedures: diagnostic laparoscopy, exploratory laparotomy, detorsion of left tube and ovary, bivalve of left ovary, and left oophoropexy.

Two coding scenarios have been suggested: The first is 58925 (Ovarian cystectomy, unilateral or bilateral) 58825 (Transposition, ovary[s]), and 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing). I hesitate to use these, though, since an ovarian cystectomy was not performed and the tube and ovary were detorsed, not transposed elsewhere.

The second option is 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s]) with modifier -22 (unusual procedural services), plus 49320.Are these appropriate?

A The diagnostic laparoscopy, presumably performed to evaluate the problem, can be coded as 49320—but be aware that you may not receive reimbursement if you planned to do the surgery laparoscopically, then converted to an open procedure.

The exploratory laparotomy is not separately bil lable, since you’ll be billing for open surgical procedures. When this happens, the exploratory becomes integral to the surgical technique.

Next is detorsion of the left ovary: CPT does not have a code for this.

You then bivalved the ovary, which is analogous to performing a wedge resection, code 58920 (Wedge resection or bisection of ovary, unilateral or bilateral).

Finally, for the oophoropexy, you are correct that code 58825 is not applicable. If you had moved the ovary out of harm’s way due to radiation treatment, the procedure is referred to as transposition of the ovary and 58825 is reported. In this case, however, I’m guessing you sutured the ovary in place so it can no longer twist. Like the detorsion, CPT has no code for this.

Your coding options are limited, but I would suggest 58920-22—which covers the bivalving, detorsion, and oophoropexy—plus 49320-59 for the diagnostic laparoscopy. (The “distinct procedure” modifier indicates that the laparoscopy was not integral to the rest of the procedure.)

As far as diagnosis, the code linked to 58920 is 620.5 (Torsion of ovary, ovarian pedicle, or fallopian tube), or 752.0 (Congenital anomalies of ovaries) if you know the problem is congenital. Consider a different diagnosis for the laparoscopy, such as lower quadrant abdominal pain (789.03 or 789.04) or ovarian pain (625.9). Finally, add V64.41 to indicate the conversion from laparoscopy to an open procedure.

Q I performed surgical treatment for torsion of the ovary using the following procedures: diagnostic laparoscopy, exploratory laparotomy, detorsion of left tube and ovary, bivalve of left ovary, and left oophoropexy.

Two coding scenarios have been suggested: The first is 58925 (Ovarian cystectomy, unilateral or bilateral) 58825 (Transposition, ovary[s]), and 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing). I hesitate to use these, though, since an ovarian cystectomy was not performed and the tube and ovary were detorsed, not transposed elsewhere.

The second option is 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s]) with modifier -22 (unusual procedural services), plus 49320.Are these appropriate?

A The diagnostic laparoscopy, presumably performed to evaluate the problem, can be coded as 49320—but be aware that you may not receive reimbursement if you planned to do the surgery laparoscopically, then converted to an open procedure.

The exploratory laparotomy is not separately bil lable, since you’ll be billing for open surgical procedures. When this happens, the exploratory becomes integral to the surgical technique.

Next is detorsion of the left ovary: CPT does not have a code for this.

You then bivalved the ovary, which is analogous to performing a wedge resection, code 58920 (Wedge resection or bisection of ovary, unilateral or bilateral).

Finally, for the oophoropexy, you are correct that code 58825 is not applicable. If you had moved the ovary out of harm’s way due to radiation treatment, the procedure is referred to as transposition of the ovary and 58825 is reported. In this case, however, I’m guessing you sutured the ovary in place so it can no longer twist. Like the detorsion, CPT has no code for this.

Your coding options are limited, but I would suggest 58920-22—which covers the bivalving, detorsion, and oophoropexy—plus 49320-59 for the diagnostic laparoscopy. (The “distinct procedure” modifier indicates that the laparoscopy was not integral to the rest of the procedure.)

As far as diagnosis, the code linked to 58920 is 620.5 (Torsion of ovary, ovarian pedicle, or fallopian tube), or 752.0 (Congenital anomalies of ovaries) if you know the problem is congenital. Consider a different diagnosis for the laparoscopy, such as lower quadrant abdominal pain (789.03 or 789.04) or ovarian pain (625.9). Finally, add V64.41 to indicate the conversion from laparoscopy to an open procedure.

Q I performed surgical treatment for torsion of the ovary using the following procedures: diagnostic laparoscopy, exploratory laparotomy, detorsion of left tube and ovary, bivalve of left ovary, and left oophoropexy.

Two coding scenarios have been suggested: The first is 58925 (Ovarian cystectomy, unilateral or bilateral) 58825 (Transposition, ovary[s]), and 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing). I hesitate to use these, though, since an ovarian cystectomy was not performed and the tube and ovary were detorsed, not transposed elsewhere.

The second option is 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s]) with modifier -22 (unusual procedural services), plus 49320.Are these appropriate?

A The diagnostic laparoscopy, presumably performed to evaluate the problem, can be coded as 49320—but be aware that you may not receive reimbursement if you planned to do the surgery laparoscopically, then converted to an open procedure.

The exploratory laparotomy is not separately bil lable, since you’ll be billing for open surgical procedures. When this happens, the exploratory becomes integral to the surgical technique.

Next is detorsion of the left ovary: CPT does not have a code for this.

You then bivalved the ovary, which is analogous to performing a wedge resection, code 58920 (Wedge resection or bisection of ovary, unilateral or bilateral).

Finally, for the oophoropexy, you are correct that code 58825 is not applicable. If you had moved the ovary out of harm’s way due to radiation treatment, the procedure is referred to as transposition of the ovary and 58825 is reported. In this case, however, I’m guessing you sutured the ovary in place so it can no longer twist. Like the detorsion, CPT has no code for this.

Your coding options are limited, but I would suggest 58920-22—which covers the bivalving, detorsion, and oophoropexy—plus 49320-59 for the diagnostic laparoscopy. (The “distinct procedure” modifier indicates that the laparoscopy was not integral to the rest of the procedure.)

As far as diagnosis, the code linked to 58920 is 620.5 (Torsion of ovary, ovarian pedicle, or fallopian tube), or 752.0 (Congenital anomalies of ovaries) if you know the problem is congenital. Consider a different diagnosis for the laparoscopy, such as lower quadrant abdominal pain (789.03 or 789.04) or ovarian pain (625.9). Finally, add V64.41 to indicate the conversion from laparoscopy to an open procedure.