Melanie Witt, RN, CPC, MA

Q Our physicians have started performing a procedure called the SURx radio frequency bladder neck suspension. The device manufacturer has recommended using either 57288 (sling operation for stress incontinence [eg, fascia or synthetic]) or 57284 (paravaginal defect repair [including repair of cystocele, stress urinary incontinence, and/or complete vaginal prolapse]), but this procedure doesn’t seem to fit either description. Do you have other suggestions?

A The radio frequency bladder neck suspension procedure is based on a device from SURx, Inc (Livermore, Calif). According to the company, their instrument restores continence by using low-power radio frequency energy to heat and shrink stretched tissue near the bladder and urethra. No sutures are used to suspend the bladder neck. The procedure can be done either transvaginally or laparoscopically.

Since this procedure does not use materials such as surgical mesh, cadaver tissue, bone screws, or staples, you cannot bill code 57288. Likewise, this is not a paravaginal defect repair, as suggested by 57284.

If you want to pick a code with a more appropriate description, try 51845 (abdomino-vaginal vesical neck suspension, with or without endoscopic control [eg, Stamey, Raz, modified Pereyra]) or 51990 (laparoscopy, surgical; urethral suspension for stress incontinence)—but if the payer considers this procedure investigational, you may run into trouble later should you be audited.

The safest course would be to bill unlisted code 53899 (unlisted procedure, urinary system) and send in documentation that supports the procedure as a viable standard of care for the presenting problem.

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 physicians have started performing a procedure called the SURx radio frequency bladder neck suspension. The device manufacturer has recommended using either 57288 (sling operation for stress incontinence [eg, fascia or synthetic]) or 57284 (paravaginal defect repair [including repair of cystocele, stress urinary incontinence, and/or complete vaginal prolapse]), but this procedure doesn’t seem to fit either description. Do you have other suggestions?

A The radio frequency bladder neck suspension procedure is based on a device from SURx, Inc (Livermore, Calif). According to the company, their instrument restores continence by using low-power radio frequency energy to heat and shrink stretched tissue near the bladder and urethra. No sutures are used to suspend the bladder neck. The procedure can be done either transvaginally or laparoscopically.

Since this procedure does not use materials such as surgical mesh, cadaver tissue, bone screws, or staples, you cannot bill code 57288. Likewise, this is not a paravaginal defect repair, as suggested by 57284.

If you want to pick a code with a more appropriate description, try 51845 (abdomino-vaginal vesical neck suspension, with or without endoscopic control [eg, Stamey, Raz, modified Pereyra]) or 51990 (laparoscopy, surgical; urethral suspension for stress incontinence)—but if the payer considers this procedure investigational, you may run into trouble later should you be audited.

The safest course would be to bill unlisted code 53899 (unlisted procedure, urinary system) and send in documentation that supports the procedure as a viable standard of care for the presenting problem.

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 physicians have started performing a procedure called the SURx radio frequency bladder neck suspension. The device manufacturer has recommended using either 57288 (sling operation for stress incontinence [eg, fascia or synthetic]) or 57284 (paravaginal defect repair [including repair of cystocele, stress urinary incontinence, and/or complete vaginal prolapse]), but this procedure doesn’t seem to fit either description. Do you have other suggestions?

A The radio frequency bladder neck suspension procedure is based on a device from SURx, Inc (Livermore, Calif). According to the company, their instrument restores continence by using low-power radio frequency energy to heat and shrink stretched tissue near the bladder and urethra. No sutures are used to suspend the bladder neck. The procedure can be done either transvaginally or laparoscopically.

Since this procedure does not use materials such as surgical mesh, cadaver tissue, bone screws, or staples, you cannot bill code 57288. Likewise, this is not a paravaginal defect repair, as suggested by 57284.

If you want to pick a code with a more appropriate description, try 51845 (abdomino-vaginal vesical neck suspension, with or without endoscopic control [eg, Stamey, Raz, modified Pereyra]) or 51990 (laparoscopy, surgical; urethral suspension for stress incontinence)—but if the payer considers this procedure investigational, you may run into trouble later should you be audited.

The safest course would be to bill unlisted code 53899 (unlisted procedure, urinary system) and send in documentation that supports the procedure as a viable standard of care for the presenting problem.

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 Five months after surgery to remove endometrial cancer, a patient came in for a follow-up visit. Since the 90-day follow-up period had passed, we billed for an office visit. The diagnostic codes used were V10.42 (personal history of endometrial cancer) and V76.2 (special screening for malignant neoplasms, cervix) for Pap screening. Because ICD-9 marks V10.42 as a secondary diagnosis, however, I fear this may be incorrect. Is it?

A Before answering this question, we need to better define the situation by making some assumptions. First, I will assume that the surgery involved removing the uterus as well as the cervix.

Second, I presume that the surgeon does not consider the patient cancer-free. ICD-9 states that a diagnosis of “personal history of cancer” is made only after all treatment is completed. At 5 months postsurgery, I am not sure this would be true—at least until 2 or 3 normal Pap interpretations assure the physician that the original cancer is gone.

And third, I assume the patient is not a Medicare beneficiary, which further changes the coding rules.

I would code the visit’s primary diagnosis as endometrial cancer, with a secondary diagnosis of V67.01 (follow-up vaginal Pap smear). This code was created to report a vaginal Pap smear after a hysterectomy for malignancy.

Once you have obtained 2 or more negative Pap results, you can use V67.01 as the primary diagnosis and V10.42 as the secondary diagnosis for each Pap smear encounter. This will take care of the ICD-9 rule stating you cannot report a “personal history” V code as the primary diagnosis.

If the patient still has her cervix, use the code for endometrial cancer for the visit’s diagnostic Pap. Once you have 2 or 3 normal Pap results, you can revert to V76.2 for the Pap interpretation. You would use this as the primary code and V10.42 for the secondary diagnosis. Note some payers will allow you to bill for a handling fee using 99000.

Q Five months after surgery to remove endometrial cancer, a patient came in for a follow-up visit. Since the 90-day follow-up period had passed, we billed for an office visit. The diagnostic codes used were V10.42 (personal history of endometrial cancer) and V76.2 (special screening for malignant neoplasms, cervix) for Pap screening. Because ICD-9 marks V10.42 as a secondary diagnosis, however, I fear this may be incorrect. Is it?

A Before answering this question, we need to better define the situation by making some assumptions. First, I will assume that the surgery involved removing the uterus as well as the cervix.

Second, I presume that the surgeon does not consider the patient cancer-free. ICD-9 states that a diagnosis of “personal history of cancer” is made only after all treatment is completed. At 5 months postsurgery, I am not sure this would be true—at least until 2 or 3 normal Pap interpretations assure the physician that the original cancer is gone.

And third, I assume the patient is not a Medicare beneficiary, which further changes the coding rules.

I would code the visit’s primary diagnosis as endometrial cancer, with a secondary diagnosis of V67.01 (follow-up vaginal Pap smear). This code was created to report a vaginal Pap smear after a hysterectomy for malignancy.

Once you have obtained 2 or more negative Pap results, you can use V67.01 as the primary diagnosis and V10.42 as the secondary diagnosis for each Pap smear encounter. This will take care of the ICD-9 rule stating you cannot report a “personal history” V code as the primary diagnosis.

If the patient still has her cervix, use the code for endometrial cancer for the visit’s diagnostic Pap. Once you have 2 or 3 normal Pap results, you can revert to V76.2 for the Pap interpretation. You would use this as the primary code and V10.42 for the secondary diagnosis. Note some payers will allow you to bill for a handling fee using 99000.

Q Five months after surgery to remove endometrial cancer, a patient came in for a follow-up visit. Since the 90-day follow-up period had passed, we billed for an office visit. The diagnostic codes used were V10.42 (personal history of endometrial cancer) and V76.2 (special screening for malignant neoplasms, cervix) for Pap screening. Because ICD-9 marks V10.42 as a secondary diagnosis, however, I fear this may be incorrect. Is it?

A Before answering this question, we need to better define the situation by making some assumptions. First, I will assume that the surgery involved removing the uterus as well as the cervix.

Second, I presume that the surgeon does not consider the patient cancer-free. ICD-9 states that a diagnosis of “personal history of cancer” is made only after all treatment is completed. At 5 months postsurgery, I am not sure this would be true—at least until 2 or 3 normal Pap interpretations assure the physician that the original cancer is gone.

And third, I assume the patient is not a Medicare beneficiary, which further changes the coding rules.

I would code the visit’s primary diagnosis as endometrial cancer, with a secondary diagnosis of V67.01 (follow-up vaginal Pap smear). This code was created to report a vaginal Pap smear after a hysterectomy for malignancy.

Once you have obtained 2 or more negative Pap results, you can use V67.01 as the primary diagnosis and V10.42 as the secondary diagnosis for each Pap smear encounter. This will take care of the ICD-9 rule stating you cannot report a “personal history” V code as the primary diagnosis.

If the patient still has her cervix, use the code for endometrial cancer for the visit’s diagnostic Pap. Once you have 2 or 3 normal Pap results, you can revert to V76.2 for the Pap interpretation. You would use this as the primary code and V10.42 for the secondary diagnosis. Note some payers will allow you to bill for a handling fee using 99000.

Q One frustrating problem we frequently encounter is when the doctor wants a patient with a recent abnormal Pap to return every 6 months for repeat cytology.

Payers do not recognize Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) with the appropriate evaluation/management (E/M) code and with 795.0X (abnormal Pap smear) as the diagnosis. Because a Pap is not a routine procedure with our E/M visits, we typically bill out the Q0091 code.

A follow-up abnormal Pap is a problem—not a preventive—E/M service. Collection is part of the exam and not coded separately.

One insurance company told me I should use laboratory codes 88142-88150. Any advice?

A The American College of Obstetricians and Gynecologists (ACOG) takes the position that specimen collection at the time of the pelvic exam should not be billed separately—but Q0091, a Healthcare Common Procedure Coding System (HCPCS) code, was created by Medicare for use with Medicare patients.

It was developed in a time when Medicare did not cover annual preventive gynecologic examinations, but did pay laboratories for interpreting cervical smears collected at these preventive visits. Medicare wanted to give physicians some reimbursement for their time spent collecting the specimen. In 1998 Medicare began covering pelvic and breast exams, but continued to pay for specimen collection for screening Pap smears.

A follow-up abnormal Pap, however, is billed as a problem—not a preventive—E/M service. In this case, Medicare agrees with ACOG that the collection is part of the exam and not coded separately.

Many private payers have also adopted this view—even those that formerly reimbursed a small fee for collection with code 99000 (handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory).

Under no circumstance should a laboratory code be billed for collecting the specimen.

Q One frustrating problem we frequently encounter is when the doctor wants a patient with a recent abnormal Pap to return every 6 months for repeat cytology.

Payers do not recognize Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) with the appropriate evaluation/management (E/M) code and with 795.0X (abnormal Pap smear) as the diagnosis. Because a Pap is not a routine procedure with our E/M visits, we typically bill out the Q0091 code.

A follow-up abnormal Pap is a problem—not a preventive—E/M service. Collection is part of the exam and not coded separately.

One insurance company told me I should use laboratory codes 88142-88150. Any advice?

A The American College of Obstetricians and Gynecologists (ACOG) takes the position that specimen collection at the time of the pelvic exam should not be billed separately—but Q0091, a Healthcare Common Procedure Coding System (HCPCS) code, was created by Medicare for use with Medicare patients.

It was developed in a time when Medicare did not cover annual preventive gynecologic examinations, but did pay laboratories for interpreting cervical smears collected at these preventive visits. Medicare wanted to give physicians some reimbursement for their time spent collecting the specimen. In 1998 Medicare began covering pelvic and breast exams, but continued to pay for specimen collection for screening Pap smears.

A follow-up abnormal Pap, however, is billed as a problem—not a preventive—E/M service. In this case, Medicare agrees with ACOG that the collection is part of the exam and not coded separately.

Many private payers have also adopted this view—even those that formerly reimbursed a small fee for collection with code 99000 (handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory).

Under no circumstance should a laboratory code be billed for collecting the specimen.

Q One frustrating problem we frequently encounter is when the doctor wants a patient with a recent abnormal Pap to return every 6 months for repeat cytology.

Payers do not recognize Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) with the appropriate evaluation/management (E/M) code and with 795.0X (abnormal Pap smear) as the diagnosis. Because a Pap is not a routine procedure with our E/M visits, we typically bill out the Q0091 code.

A follow-up abnormal Pap is a problem—not a preventive—E/M service. Collection is part of the exam and not coded separately.

One insurance company told me I should use laboratory codes 88142-88150. Any advice?

A The American College of Obstetricians and Gynecologists (ACOG) takes the position that specimen collection at the time of the pelvic exam should not be billed separately—but Q0091, a Healthcare Common Procedure Coding System (HCPCS) code, was created by Medicare for use with Medicare patients.

It was developed in a time when Medicare did not cover annual preventive gynecologic examinations, but did pay laboratories for interpreting cervical smears collected at these preventive visits. Medicare wanted to give physicians some reimbursement for their time spent collecting the specimen. In 1998 Medicare began covering pelvic and breast exams, but continued to pay for specimen collection for screening Pap smears.

A follow-up abnormal Pap, however, is billed as a problem—not a preventive—E/M service. In this case, Medicare agrees with ACOG that the collection is part of the exam and not coded separately.

Many private payers have also adopted this view—even those that formerly reimbursed a small fee for collection with code 99000 (handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory).

Under no circumstance should a laboratory code be billed for collecting the specimen.

Q I need a diagnosis code for vaginal bleeding 8 weeks postpartum. The physician says it is possibly retained products of conception. How would I code this?

A The standard postpartum period is 6 weeks. Beyond that time you can report this as a late effect of pregnancy (677)—however, since this code cannot be used as a primary diagnosis, you must look for another code to explain the symptom.

If there is a finding of retained products of conception, use 667.04 (retained placenta without hemorrhage) or 667.14 (retained portions of placenta or membranes, without hemorrhage) along with 677.

If the report shows no products but the physician believes the bleeding is related to pregnancy, your choices include:

• 665.34 for a laceration on the cervix,
  
• 665.74 for a hematoma of the vagina,
  
• 665.84 for some “other” specified obstetrical trauma, or
  
• 665.94 for an unspecified trauma.
  

If none of these fit or if the bleeding turns out to be unrelated to the pregnancy, bill 626.8 from the Gyn chapter for other dysfunctional bleeding.

Q I need a diagnosis code for vaginal bleeding 8 weeks postpartum. The physician says it is possibly retained products of conception. How would I code this?

A The standard postpartum period is 6 weeks. Beyond that time you can report this as a late effect of pregnancy (677)—however, since this code cannot be used as a primary diagnosis, you must look for another code to explain the symptom.

If there is a finding of retained products of conception, use 667.04 (retained placenta without hemorrhage) or 667.14 (retained portions of placenta or membranes, without hemorrhage) along with 677.

If the report shows no products but the physician believes the bleeding is related to pregnancy, your choices include:

• 665.34 for a laceration on the cervix,
  
• 665.74 for a hematoma of the vagina,
  
• 665.84 for some “other” specified obstetrical trauma, or
  
• 665.94 for an unspecified trauma.
  

If none of these fit or if the bleeding turns out to be unrelated to the pregnancy, bill 626.8 from the Gyn chapter for other dysfunctional bleeding.

Q I need a diagnosis code for vaginal bleeding 8 weeks postpartum. The physician says it is possibly retained products of conception. How would I code this?

A The standard postpartum period is 6 weeks. Beyond that time you can report this as a late effect of pregnancy (677)—however, since this code cannot be used as a primary diagnosis, you must look for another code to explain the symptom.

If there is a finding of retained products of conception, use 667.04 (retained placenta without hemorrhage) or 667.14 (retained portions of placenta or membranes, without hemorrhage) along with 677.

If the report shows no products but the physician believes the bleeding is related to pregnancy, your choices include:

• 665.34 for a laceration on the cervix,
  
• 665.74 for a hematoma of the vagina,
  
• 665.84 for some “other” specified obstetrical trauma, or
  
• 665.94 for an unspecified trauma.
  

If none of these fit or if the bleeding turns out to be unrelated to the pregnancy, bill 626.8 from the Gyn chapter for other dysfunctional bleeding.

Q My physician performed a laparoscopic supracervical hysterectomy with morcellation. Would I bill 58550-52?

A This question has 2 parts: how to bill for a laparoscopic supracervical hysterectomy, and how to account for the morcellation.

Currently, no code exists for laparoscopic supracervical hysterectomy. Your proposed choice, 58550-52 (laparoscopy surgical; with vaginal hysterectomy for uterus 250 grams or less; reduced service), is sometimes used, but payers just as frequently accept unlisted code 58578 (unlisted laparoscopy procedure, uterus). The latter option, with documentation, sometimes results in prompter and fairer reimbursement over the -52 modifier option. The reason: The procedure is more completely described via the submitted documentation, and payers are less likely to reduce their allowable, even though the cervix was left in place.

When morcellation of the uterus is performed, however, the situation changes: This technique is performed to shred and extract a very large uterus, and CPT has a code (58553) for laparoscopic vaginal hysterectomy for a uterus weighing more than 250 g. Thus, your options would be to bill either 58553-52 or the unlisted code 58578.

Q My physician performed a laparoscopic supracervical hysterectomy with morcellation. Would I bill 58550-52?

A This question has 2 parts: how to bill for a laparoscopic supracervical hysterectomy, and how to account for the morcellation.

Currently, no code exists for laparoscopic supracervical hysterectomy. Your proposed choice, 58550-52 (laparoscopy surgical; with vaginal hysterectomy for uterus 250 grams or less; reduced service), is sometimes used, but payers just as frequently accept unlisted code 58578 (unlisted laparoscopy procedure, uterus). The latter option, with documentation, sometimes results in prompter and fairer reimbursement over the -52 modifier option. The reason: The procedure is more completely described via the submitted documentation, and payers are less likely to reduce their allowable, even though the cervix was left in place.

When morcellation of the uterus is performed, however, the situation changes: This technique is performed to shred and extract a very large uterus, and CPT has a code (58553) for laparoscopic vaginal hysterectomy for a uterus weighing more than 250 g. Thus, your options would be to bill either 58553-52 or the unlisted code 58578.

Q My physician performed a laparoscopic supracervical hysterectomy with morcellation. Would I bill 58550-52?

A This question has 2 parts: how to bill for a laparoscopic supracervical hysterectomy, and how to account for the morcellation.

Currently, no code exists for laparoscopic supracervical hysterectomy. Your proposed choice, 58550-52 (laparoscopy surgical; with vaginal hysterectomy for uterus 250 grams or less; reduced service), is sometimes used, but payers just as frequently accept unlisted code 58578 (unlisted laparoscopy procedure, uterus). The latter option, with documentation, sometimes results in prompter and fairer reimbursement over the -52 modifier option. The reason: The procedure is more completely described via the submitted documentation, and payers are less likely to reduce their allowable, even though the cervix was left in place.

When morcellation of the uterus is performed, however, the situation changes: This technique is performed to shred and extract a very large uterus, and CPT has a code (58553) for laparoscopic vaginal hysterectomy for a uterus weighing more than 250 g. Thus, your options would be to bill either 58553-52 or the unlisted code 58578.

Q Genetic testing for a patient with a personal history of breast cancer revealed a high risk for ovarian cancer. She is scheduled to have a total vaginal hysterectomy and bilateral oophorectomy as a precautionary measure. Which diagnosis do I use? She has no signs or symptoms.

A Use V50.49 (other prophylactic organ removal), V50.42 (prophylactic organ removal of ovary), and V10.3 (personal history of breast cancer). If you are obtaining prior authorization, submit a letter with the request in which you list these codes as the reason for the surgery and explain the circumstances.

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 Genetic testing for a patient with a personal history of breast cancer revealed a high risk for ovarian cancer. She is scheduled to have a total vaginal hysterectomy and bilateral oophorectomy as a precautionary measure. Which diagnosis do I use? She has no signs or symptoms.

A Use V50.49 (other prophylactic organ removal), V50.42 (prophylactic organ removal of ovary), and V10.3 (personal history of breast cancer). If you are obtaining prior authorization, submit a letter with the request in which you list these codes as the reason for the surgery and explain the circumstances.

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 Genetic testing for a patient with a personal history of breast cancer revealed a high risk for ovarian cancer. She is scheduled to have a total vaginal hysterectomy and bilateral oophorectomy as a precautionary measure. Which diagnosis do I use? She has no signs or symptoms.

A Use V50.49 (other prophylactic organ removal), V50.42 (prophylactic organ removal of ovary), and V10.3 (personal history of breast cancer). If you are obtaining prior authorization, submit a letter with the request in which you list these codes as the reason for the surgery and explain the circumstances.

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 Which CPT code would I use for vaginal cuff repair?

A This is one of the most frequently asked coding questions—and one of the toughest to answer.

Most coders suggest using either an unlisted code or the repair codes from CPT’s integumentary section. The circumstance of the repair will determine which course of action is best:

• You cannot use the codes for a simple (12001-12007) or intermediate repair (12041-12047), because they specify external genitalia.
  
• If the repair is due to the original sutures coming loose, you can try 12020 (treatment of superficial wound dehiscence; simple closure).
  
• Codes 13131–13133 (repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet;…) specify only “genitalia,” which includes internal structures of the vaginal canal. However, you may use these codes only if the patient’s record lists the size of the repair and the repair meets the definition of “complex” as outlined in the CPT guideline.
  
• If the repair is necessary because of an injury, use 57200 (colporrhaphy, suture of injury of vagina [nonobstetrical]).
  
• If none of these fit, you will be stuck with 58999 (unlisted procedure, female genital system [nonobstetrical]).
  
• Remember to add modifier -78 (return to the operating room for a related procedure during the postoperative period) if the repair is related to previous surgery and you are in the global period.
  

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 Which CPT code would I use for vaginal cuff repair?

A This is one of the most frequently asked coding questions—and one of the toughest to answer.

Most coders suggest using either an unlisted code or the repair codes from CPT’s integumentary section. The circumstance of the repair will determine which course of action is best:

• You cannot use the codes for a simple (12001-12007) or intermediate repair (12041-12047), because they specify external genitalia.
  
• If the repair is due to the original sutures coming loose, you can try 12020 (treatment of superficial wound dehiscence; simple closure).
  
• Codes 13131–13133 (repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet;…) specify only “genitalia,” which includes internal structures of the vaginal canal. However, you may use these codes only if the patient’s record lists the size of the repair and the repair meets the definition of “complex” as outlined in the CPT guideline.
  
• If the repair is necessary because of an injury, use 57200 (colporrhaphy, suture of injury of vagina [nonobstetrical]).
  
• If none of these fit, you will be stuck with 58999 (unlisted procedure, female genital system [nonobstetrical]).
  
• Remember to add modifier -78 (return to the operating room for a related procedure during the postoperative period) if the repair is related to previous surgery and you are in the global period.
  

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 Which CPT code would I use for vaginal cuff repair?

A This is one of the most frequently asked coding questions—and one of the toughest to answer.

Most coders suggest using either an unlisted code or the repair codes from CPT’s integumentary section. The circumstance of the repair will determine which course of action is best:

• You cannot use the codes for a simple (12001-12007) or intermediate repair (12041-12047), because they specify external genitalia.
  
• If the repair is due to the original sutures coming loose, you can try 12020 (treatment of superficial wound dehiscence; simple closure).
  
• Codes 13131–13133 (repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet;…) specify only “genitalia,” which includes internal structures of the vaginal canal. However, you may use these codes only if the patient’s record lists the size of the repair and the repair meets the definition of “complex” as outlined in the CPT guideline.
  
• If the repair is necessary because of an injury, use 57200 (colporrhaphy, suture of injury of vagina [nonobstetrical]).
  
• If none of these fit, you will be stuck with 58999 (unlisted procedure, female genital system [nonobstetrical]).
  
• Remember to add modifier -78 (return to the operating room for a related procedure during the postoperative period) if the repair is related to previous surgery and you are in the global period.
  

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 have searched, but cannot find a code for what the physician is calling a “friable cervix.” Can you help?

A The friable cervix is one that is prone to bleeding. The underlying cause is usually chlamydia infection, cervical erosion, or, sometimes, cervical cancer.

If the physician is trying to rule out infection or if all tests are negative, use the code for the patient’s symptom. Possible choices include cervical inflammation (616.0), cervical erosion (622.0), pain with intercourse (625.0), and other abnormal bleeding from the female genital tract (626.8). Once the reason for the friable cervix is determined, that becomes the diagnosis.

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 have searched, but cannot find a code for what the physician is calling a “friable cervix.” Can you help?

A The friable cervix is one that is prone to bleeding. The underlying cause is usually chlamydia infection, cervical erosion, or, sometimes, cervical cancer.

If the physician is trying to rule out infection or if all tests are negative, use the code for the patient’s symptom. Possible choices include cervical inflammation (616.0), cervical erosion (622.0), pain with intercourse (625.0), and other abnormal bleeding from the female genital tract (626.8). Once the reason for the friable cervix is determined, that becomes the diagnosis.

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 have searched, but cannot find a code for what the physician is calling a “friable cervix.” Can you help?

A The friable cervix is one that is prone to bleeding. The underlying cause is usually chlamydia infection, cervical erosion, or, sometimes, cervical cancer.

If the physician is trying to rule out infection or if all tests are negative, use the code for the patient’s symptom. Possible choices include cervical inflammation (616.0), cervical erosion (622.0), pain with intercourse (625.0), and other abnormal bleeding from the female genital tract (626.8). Once the reason for the friable cervix is determined, that becomes the diagnosis.

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 Some pregnant patients (trauma cases, etc) go through our hospital emergency room (ER), but most go to our labor and delivery triage center, which is staffed by residents 24 hours a day, with an in-house attending always available. Some universities I know use ER codes for triage-center billing, because they feel it meets the requirements of an ER. Is this acceptable?

A No. Both Medicare and CPT guidelines state that to use the ER services codes, you must provide the service in the hospital’s designated emergency room or department. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. Within this definition, there is the tacit understanding that such care must be provided to all, without discrimination as to gender or age. You have stated that your hospital has a designated ER; thus, the emergency services codes (99281-99285) are appropriate only when care is provided in that setting.

If physicians in the labor and delivery center are seeing pregnant patients for triage, your coding choices are:

• observation care admission (99218-99220),
  
• observation care discharge (99217),
  
• same-day observation admission and discharge (99234-99236),
  
• outpatient care (99201-99215), or
  
• outpatient consultations (99241-99245).
  

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 Some pregnant patients (trauma cases, etc) go through our hospital emergency room (ER), but most go to our labor and delivery triage center, which is staffed by residents 24 hours a day, with an in-house attending always available. Some universities I know use ER codes for triage-center billing, because they feel it meets the requirements of an ER. Is this acceptable?

A No. Both Medicare and CPT guidelines state that to use the ER services codes, you must provide the service in the hospital’s designated emergency room or department. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. Within this definition, there is the tacit understanding that such care must be provided to all, without discrimination as to gender or age. You have stated that your hospital has a designated ER; thus, the emergency services codes (99281-99285) are appropriate only when care is provided in that setting.

If physicians in the labor and delivery center are seeing pregnant patients for triage, your coding choices are:

• observation care admission (99218-99220),
  
• observation care discharge (99217),
  
• same-day observation admission and discharge (99234-99236),
  
• outpatient care (99201-99215), or
  
• outpatient consultations (99241-99245).
  

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 Some pregnant patients (trauma cases, etc) go through our hospital emergency room (ER), but most go to our labor and delivery triage center, which is staffed by residents 24 hours a day, with an in-house attending always available. Some universities I know use ER codes for triage-center billing, because they feel it meets the requirements of an ER. Is this acceptable?

A No. Both Medicare and CPT guidelines state that to use the ER services codes, you must provide the service in the hospital’s designated emergency room or department. The emergency department is defined as an organized hospital-based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention. Within this definition, there is the tacit understanding that such care must be provided to all, without discrimination as to gender or age. You have stated that your hospital has a designated ER; thus, the emergency services codes (99281-99285) are appropriate only when care is provided in that setting.

If physicians in the labor and delivery center are seeing pregnant patients for triage, your coding choices are:

• observation care admission (99218-99220),
  
• observation care discharge (99217),
  
• same-day observation admission and discharge (99234-99236),
  
• outpatient care (99201-99215), or
  
• outpatient consultations (99241-99245).
  

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 One of my doctors performed a postcoital analysis of a patient’s mucous due to infertility issues. The physician called it a Sims-Huhner test. How should I code for this service?

A The postcoital test—also known as the Sims-Huhner, or Huhner, test—analyzes the cervical canal after sexual intercourse to determine whether sperm are present and moving. The cervical mucus also may be evaluated to determine its elasticity and drying pattern.

The test is performed 1 to 2 days before ovulation is expected, when the cervical mucus is thin, elastic, and easily penetrable by sperm. Two to 4 hours after the couple has sexual intercourse (without lubricants), a clinician collects the specimen and analyzes it under a microscope.

As it happens, there is a non-CPT code for this procedure: code Q0115, (postcoital direct, qualitative examinations of vaginal or cervical mucous). It is part of the HIPAA-specified code set, and as such may be used to bill for the procedure. Note this is considered a physician-performed microscopy (PPM) procedure, which requires a Clinical Laboratories Improvement Amendments PPM certificate.

A good second choice is the CPT code 89300 (presence and/or motility of sperm including Huhner test [postcoital]), which includes semen analysis. Some infertility physicians I have spoken with recommend using 89300 for the Huhner test even when the semen analysis is not performed. In this scenario, you might consider adding the modifier -52 (reduced services) to be truly “coding accurate.”

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 One of my doctors performed a postcoital analysis of a patient’s mucous due to infertility issues. The physician called it a Sims-Huhner test. How should I code for this service?

A The postcoital test—also known as the Sims-Huhner, or Huhner, test—analyzes the cervical canal after sexual intercourse to determine whether sperm are present and moving. The cervical mucus also may be evaluated to determine its elasticity and drying pattern.

The test is performed 1 to 2 days before ovulation is expected, when the cervical mucus is thin, elastic, and easily penetrable by sperm. Two to 4 hours after the couple has sexual intercourse (without lubricants), a clinician collects the specimen and analyzes it under a microscope.

As it happens, there is a non-CPT code for this procedure: code Q0115, (postcoital direct, qualitative examinations of vaginal or cervical mucous). It is part of the HIPAA-specified code set, and as such may be used to bill for the procedure. Note this is considered a physician-performed microscopy (PPM) procedure, which requires a Clinical Laboratories Improvement Amendments PPM certificate.

A good second choice is the CPT code 89300 (presence and/or motility of sperm including Huhner test [postcoital]), which includes semen analysis. Some infertility physicians I have spoken with recommend using 89300 for the Huhner test even when the semen analysis is not performed. In this scenario, you might consider adding the modifier -52 (reduced services) to be truly “coding accurate.”

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 One of my doctors performed a postcoital analysis of a patient’s mucous due to infertility issues. The physician called it a Sims-Huhner test. How should I code for this service?

A The postcoital test—also known as the Sims-Huhner, or Huhner, test—analyzes the cervical canal after sexual intercourse to determine whether sperm are present and moving. The cervical mucus also may be evaluated to determine its elasticity and drying pattern.

The test is performed 1 to 2 days before ovulation is expected, when the cervical mucus is thin, elastic, and easily penetrable by sperm. Two to 4 hours after the couple has sexual intercourse (without lubricants), a clinician collects the specimen and analyzes it under a microscope.

As it happens, there is a non-CPT code for this procedure: code Q0115, (postcoital direct, qualitative examinations of vaginal or cervical mucous). It is part of the HIPAA-specified code set, and as such may be used to bill for the procedure. Note this is considered a physician-performed microscopy (PPM) procedure, which requires a Clinical Laboratories Improvement Amendments PPM certificate.

A good second choice is the CPT code 89300 (presence and/or motility of sperm including Huhner test [postcoital]), which includes semen analysis. Some infertility physicians I have spoken with recommend using 89300 for the Huhner test even when the semen analysis is not performed. In this scenario, you might consider adding the modifier -52 (reduced services) to be truly “coding accurate.”

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.