Melanie Witt, RN, CPC, MA

Q Can we bill for our ultrasound technician using “incident to” rules? Our physician, though not present for the procedure, does the interpretation while the technician performs the scan.

A The “incident to” rules have no relevance when you are billing for ultrasound procedures. The scan, when performed in your office, is comprised of 2 parts:

• a professional component, which consists of the physician’s interpretation of the results and his or her written report, and
  
• a technical component, consisting of the machine and supplies as well as the sonographer who performs the scan.
  

Therefore, when the ultrasound is performed in your office on your own equipment, you always bill the code under the physician’s number, without a modifier.

Q Can we bill for our ultrasound technician using “incident to” rules? Our physician, though not present for the procedure, does the interpretation while the technician performs the scan.

A The “incident to” rules have no relevance when you are billing for ultrasound procedures. The scan, when performed in your office, is comprised of 2 parts:

• a professional component, which consists of the physician’s interpretation of the results and his or her written report, and
  
• a technical component, consisting of the machine and supplies as well as the sonographer who performs the scan.
  

Therefore, when the ultrasound is performed in your office on your own equipment, you always bill the code under the physician’s number, without a modifier.

Q Can we bill for our ultrasound technician using “incident to” rules? Our physician, though not present for the procedure, does the interpretation while the technician performs the scan.

A The “incident to” rules have no relevance when you are billing for ultrasound procedures. The scan, when performed in your office, is comprised of 2 parts:

• a professional component, which consists of the physician’s interpretation of the results and his or her written report, and
  
• a technical component, consisting of the machine and supplies as well as the sonographer who performs the scan.
  

Therefore, when the ultrasound is performed in your office on your own equipment, you always bill the code under the physician’s number, without a modifier.

Q Our physician did a laparotomy with evacuation of hemoperitoneum and a transvaginal repair of a cervicovaginal laceration. Both were performed on the same day as delivery. I was considering code 49020 for the hemoperitoneum, but am not sure about the laceration repair. Can you help?

A If your physician performed the delivery, the laceration repair will likely be included in the global service—unless it was a 3rd-degree or 4th-degree laceration. For such extensive wounds, look at codes 12001-12007, 12041-12047, and 13131-13133 to see which fits the situation described in the operative report.

If the laceration repair was done at the time of delivery, add modifier -51 (multiple procedure) to the repair code; if the patient was brought back to the operating room for the procedure, use modifier -78 (return to operating room for a related procedure during the postoperative period). Alternatively, you might consider adding modifier -22 (unusual services) to the delivery code for the documented significant additional work involved with the repair.

As for the return to the operating room for blood evacuation: You cannot use 49020, as that code is for draining a peritoneal abscess. Code 49002 (reopening of recent laparotomy) would also be incorrect, unless the delivery was by cesarean. For vaginal delivery, I would use either 49000 (exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) or 35840 (exploration for postoperative hemorrhage, thrombosis or infection; abdomen).

Note that I could find no CPT reference regarding the intended use of code 35840 as opposed to 49000. However, 35840 is located in CPT’s cardiovascular-system section; this may influence a payer as to acceptable linking diagnoses. The short descriptors for these 2 codes differ slightly: Code 35840 says “exploration of abdominal vessels” while 49000 reads “exploration of abdomen.” Code 35840, by the way, has fewer relative value units than 49000.

Q Our physician did a laparotomy with evacuation of hemoperitoneum and a transvaginal repair of a cervicovaginal laceration. Both were performed on the same day as delivery. I was considering code 49020 for the hemoperitoneum, but am not sure about the laceration repair. Can you help?

A If your physician performed the delivery, the laceration repair will likely be included in the global service—unless it was a 3rd-degree or 4th-degree laceration. For such extensive wounds, look at codes 12001-12007, 12041-12047, and 13131-13133 to see which fits the situation described in the operative report.

If the laceration repair was done at the time of delivery, add modifier -51 (multiple procedure) to the repair code; if the patient was brought back to the operating room for the procedure, use modifier -78 (return to operating room for a related procedure during the postoperative period). Alternatively, you might consider adding modifier -22 (unusual services) to the delivery code for the documented significant additional work involved with the repair.

As for the return to the operating room for blood evacuation: You cannot use 49020, as that code is for draining a peritoneal abscess. Code 49002 (reopening of recent laparotomy) would also be incorrect, unless the delivery was by cesarean. For vaginal delivery, I would use either 49000 (exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) or 35840 (exploration for postoperative hemorrhage, thrombosis or infection; abdomen).

Note that I could find no CPT reference regarding the intended use of code 35840 as opposed to 49000. However, 35840 is located in CPT’s cardiovascular-system section; this may influence a payer as to acceptable linking diagnoses. The short descriptors for these 2 codes differ slightly: Code 35840 says “exploration of abdominal vessels” while 49000 reads “exploration of abdomen.” Code 35840, by the way, has fewer relative value units than 49000.

Q Our physician did a laparotomy with evacuation of hemoperitoneum and a transvaginal repair of a cervicovaginal laceration. Both were performed on the same day as delivery. I was considering code 49020 for the hemoperitoneum, but am not sure about the laceration repair. Can you help?

A If your physician performed the delivery, the laceration repair will likely be included in the global service—unless it was a 3rd-degree or 4th-degree laceration. For such extensive wounds, look at codes 12001-12007, 12041-12047, and 13131-13133 to see which fits the situation described in the operative report.

If the laceration repair was done at the time of delivery, add modifier -51 (multiple procedure) to the repair code; if the patient was brought back to the operating room for the procedure, use modifier -78 (return to operating room for a related procedure during the postoperative period). Alternatively, you might consider adding modifier -22 (unusual services) to the delivery code for the documented significant additional work involved with the repair.

As for the return to the operating room for blood evacuation: You cannot use 49020, as that code is for draining a peritoneal abscess. Code 49002 (reopening of recent laparotomy) would also be incorrect, unless the delivery was by cesarean. For vaginal delivery, I would use either 49000 (exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) or 35840 (exploration for postoperative hemorrhage, thrombosis or infection; abdomen).

Note that I could find no CPT reference regarding the intended use of code 35840 as opposed to 49000. However, 35840 is located in CPT’s cardiovascular-system section; this may influence a payer as to acceptable linking diagnoses. The short descriptors for these 2 codes differ slightly: Code 35840 says “exploration of abdominal vessels” while 49000 reads “exploration of abdomen.” Code 35840, by the way, has fewer relative value units than 49000.

Q Our physician performed a chemical cauterization of the cervix for a patient with bleeding. I found a code for chemical cauterization of granulation tissue (17250) and one for cautery of cervix, electro or thermal (57510), but neither seems right. Do you have any suggestions?

A There is no specific code for chemical cautery of the cervix. This is because, normally, the procedure simply involves the application of a silver nitrate stick to the cervix, and does not require specialized equipment or expensive materials.

If you think you can make a case for significant physician work in applying the silver nitrate, you can bill this as an unlisted procedure (58999). Otherwise, I would simply consider this incidental to the exam and bill only an evaluation and management service. You can, however, bill for the supplies using 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered).

Q Our physician performed a chemical cauterization of the cervix for a patient with bleeding. I found a code for chemical cauterization of granulation tissue (17250) and one for cautery of cervix, electro or thermal (57510), but neither seems right. Do you have any suggestions?

A There is no specific code for chemical cautery of the cervix. This is because, normally, the procedure simply involves the application of a silver nitrate stick to the cervix, and does not require specialized equipment or expensive materials.

If you think you can make a case for significant physician work in applying the silver nitrate, you can bill this as an unlisted procedure (58999). Otherwise, I would simply consider this incidental to the exam and bill only an evaluation and management service. You can, however, bill for the supplies using 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered).

Q Our physician performed a chemical cauterization of the cervix for a patient with bleeding. I found a code for chemical cauterization of granulation tissue (17250) and one for cautery of cervix, electro or thermal (57510), but neither seems right. Do you have any suggestions?

A There is no specific code for chemical cautery of the cervix. This is because, normally, the procedure simply involves the application of a silver nitrate stick to the cervix, and does not require specialized equipment or expensive materials.

If you think you can make a case for significant physician work in applying the silver nitrate, you can bill this as an unlisted procedure (58999). Otherwise, I would simply consider this incidental to the exam and bill only an evaluation and management service. You can, however, bill for the supplies using 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered).

Q We have a patient who, 3 weeks after a vaginal hysterectomy, presented to the emergency room with significant vaginal bleeding. She was taken to the operating room for a vaginal-approach exploration and suture of the vaginal cuff. How would I code for this?

A This situation seems to occur quite frequently, judging from the number of questions I get on the topic. There is no CPT code specific to the repair of the vaginal cuff. The closest codes seem to be:

• 57200 (colporrhaphy, suture of injury to vagina [nonobstetrical]),
  
• the complex repair codes 13131-13133 (repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet),
  
• 13160 (secondary closure of surgical wound or dehiscence, extensive or complicated), or
  
• the unlisted code 58999.
  

Of the 4 choices, I favor the complex repair codes, since they specifically mention repair of the genitalia—which would include both the external and internal structures. The downside is that, in order to use these codes, the size of the repair must be documented and more than just a layered closure must be used. Note that the codes for simple and intermediate repair (12001-12007 and 12041-12047) specify external genitalia, and therefore could not be used in this instance.

In order to select code 13160, the repair would have to be extensive or complicated—and, of course, the documentation would need to support that.

I am not sure how payers will look upon code 57200. You must use diagnosis code 998.31 (disruption of internal operation wound) to indicate the reason for the repair, but some payers may not consider this a match with 57200.

Picking the unlisted code is the least desirable option, unless the physician did something other than repair the vaginal cuff.

No matter which code you choose, remember to add modifier -78 (return to operating room for a related procedure during the postoperative period).

Q We have a patient who, 3 weeks after a vaginal hysterectomy, presented to the emergency room with significant vaginal bleeding. She was taken to the operating room for a vaginal-approach exploration and suture of the vaginal cuff. How would I code for this?

A This situation seems to occur quite frequently, judging from the number of questions I get on the topic. There is no CPT code specific to the repair of the vaginal cuff. The closest codes seem to be:

• 57200 (colporrhaphy, suture of injury to vagina [nonobstetrical]),
  
• the complex repair codes 13131-13133 (repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet),
  
• 13160 (secondary closure of surgical wound or dehiscence, extensive or complicated), or
  
• the unlisted code 58999.
  

Of the 4 choices, I favor the complex repair codes, since they specifically mention repair of the genitalia—which would include both the external and internal structures. The downside is that, in order to use these codes, the size of the repair must be documented and more than just a layered closure must be used. Note that the codes for simple and intermediate repair (12001-12007 and 12041-12047) specify external genitalia, and therefore could not be used in this instance.

In order to select code 13160, the repair would have to be extensive or complicated—and, of course, the documentation would need to support that.

I am not sure how payers will look upon code 57200. You must use diagnosis code 998.31 (disruption of internal operation wound) to indicate the reason for the repair, but some payers may not consider this a match with 57200.

Picking the unlisted code is the least desirable option, unless the physician did something other than repair the vaginal cuff.

No matter which code you choose, remember to add modifier -78 (return to operating room for a related procedure during the postoperative period).

Q We have a patient who, 3 weeks after a vaginal hysterectomy, presented to the emergency room with significant vaginal bleeding. She was taken to the operating room for a vaginal-approach exploration and suture of the vaginal cuff. How would I code for this?

A This situation seems to occur quite frequently, judging from the number of questions I get on the topic. There is no CPT code specific to the repair of the vaginal cuff. The closest codes seem to be:

• 57200 (colporrhaphy, suture of injury to vagina [nonobstetrical]),
  
• the complex repair codes 13131-13133 (repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet),
  
• 13160 (secondary closure of surgical wound or dehiscence, extensive or complicated), or
  
• the unlisted code 58999.
  

Of the 4 choices, I favor the complex repair codes, since they specifically mention repair of the genitalia—which would include both the external and internal structures. The downside is that, in order to use these codes, the size of the repair must be documented and more than just a layered closure must be used. Note that the codes for simple and intermediate repair (12001-12007 and 12041-12047) specify external genitalia, and therefore could not be used in this instance.

In order to select code 13160, the repair would have to be extensive or complicated—and, of course, the documentation would need to support that.

I am not sure how payers will look upon code 57200. You must use diagnosis code 998.31 (disruption of internal operation wound) to indicate the reason for the repair, but some payers may not consider this a match with 57200.

Picking the unlisted code is the least desirable option, unless the physician did something other than repair the vaginal cuff.

No matter which code you choose, remember to add modifier -78 (return to operating room for a related procedure during the postoperative period).

Q Our physician performed colposcopy-directed vaginal biopsies and a transvaginal tape (TVT) procedure with cystoscopy. The diagnosis was a Pap result consistent with vaginal intraepithelial neoplasia I (VIN I). How should these procedures be coded?

A First, I hope there was another diagnosis besides VIN I—this condition justifies the directed biopsies but not the TVT procedure, which would be done for stress urinary incontinence (ICD-9-CM code 625.6).

For the TVT, the code you use will depend on the surgical approach. Use code 57288 for a vaginal approach or code 51992 for a laparoscopic approach. This sling procedure would be listed first on the claim, since it is the most extensive procedure.

Coding for the directed biopsies depends on whether your payer accepts the new CPT code for colposcopy with vaginal biopsy(s) (57421). If so, the claim should be submitted as 57288 or 51992 + 57421-51.

If your payer is still using the 2002 CPT codes, the only way to capture the colposcopy with vaginal biopsy would be to bill 2 codes: 57452 for the colposcopy plus either 57100 for a simple biopsy or 57105 for a biopsy that required suturing. Note that codes 57100 and 57452 are CPT “separate procedures” that are sometimes bundled together by the payer. For this reason, you’ll want to add modifier -59 (distinct procedure) to these codes. The result for these additional procedures: 57100-59-51 + 57452-59-51 or 57105-51 + 57452-59-51.

Some payers require modifier -51 (multiple procedure) be added when listing a second or third procedure, so their computer can handle the claim from a fee-reduction standpoint.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Our physician performed colposcopy-directed vaginal biopsies and a transvaginal tape (TVT) procedure with cystoscopy. The diagnosis was a Pap result consistent with vaginal intraepithelial neoplasia I (VIN I). How should these procedures be coded?

A First, I hope there was another diagnosis besides VIN I—this condition justifies the directed biopsies but not the TVT procedure, which would be done for stress urinary incontinence (ICD-9-CM code 625.6).

For the TVT, the code you use will depend on the surgical approach. Use code 57288 for a vaginal approach or code 51992 for a laparoscopic approach. This sling procedure would be listed first on the claim, since it is the most extensive procedure.

Coding for the directed biopsies depends on whether your payer accepts the new CPT code for colposcopy with vaginal biopsy(s) (57421). If so, the claim should be submitted as 57288 or 51992 + 57421-51.

If your payer is still using the 2002 CPT codes, the only way to capture the colposcopy with vaginal biopsy would be to bill 2 codes: 57452 for the colposcopy plus either 57100 for a simple biopsy or 57105 for a biopsy that required suturing. Note that codes 57100 and 57452 are CPT “separate procedures” that are sometimes bundled together by the payer. For this reason, you’ll want to add modifier -59 (distinct procedure) to these codes. The result for these additional procedures: 57100-59-51 + 57452-59-51 or 57105-51 + 57452-59-51.

Some payers require modifier -51 (multiple procedure) be added when listing a second or third procedure, so their computer can handle the claim from a fee-reduction standpoint.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Our physician performed colposcopy-directed vaginal biopsies and a transvaginal tape (TVT) procedure with cystoscopy. The diagnosis was a Pap result consistent with vaginal intraepithelial neoplasia I (VIN I). How should these procedures be coded?

A First, I hope there was another diagnosis besides VIN I—this condition justifies the directed biopsies but not the TVT procedure, which would be done for stress urinary incontinence (ICD-9-CM code 625.6).

For the TVT, the code you use will depend on the surgical approach. Use code 57288 for a vaginal approach or code 51992 for a laparoscopic approach. This sling procedure would be listed first on the claim, since it is the most extensive procedure.

Coding for the directed biopsies depends on whether your payer accepts the new CPT code for colposcopy with vaginal biopsy(s) (57421). If so, the claim should be submitted as 57288 or 51992 + 57421-51.

If your payer is still using the 2002 CPT codes, the only way to capture the colposcopy with vaginal biopsy would be to bill 2 codes: 57452 for the colposcopy plus either 57100 for a simple biopsy or 57105 for a biopsy that required suturing. Note that codes 57100 and 57452 are CPT “separate procedures” that are sometimes bundled together by the payer. For this reason, you’ll want to add modifier -59 (distinct procedure) to these codes. The result for these additional procedures: 57100-59-51 + 57452-59-51 or 57105-51 + 57452-59-51.

Some payers require modifier -51 (multiple procedure) be added when listing a second or third procedure, so their computer can handle the claim from a fee-reduction standpoint.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We recently had an obstetric patient who was admitted for observation due to upper-quadrant abdominal pain. During her stay, a general surgeon performed a cholecystectomy. She was discharged 6 days after admission, but immediately went into preterm labor, delivering at home at 27 weeks’ gestation. She and the baby were readmitted on the day after her discharge. How do I charge this?

A Did you provide all of the obstetric care except for the delivery? If so, you can bill the global obstetric service, should the payer allow, but should also add modifier -52 to indicate reduced services.

Alternatively, you may want to bill only for those services that were actually performed, by splitting the care into its component parts. This would mean billing for:

• the antepartum care using 59425 (4 to 6 visits) or 59426 (7 or more visits);
  
• the hospital admission after delivery (codes 99221-99223);
  
• the delivery of the placenta (code 59414) or an episiotomy (code 59300), if performed after the delivery; and
  
• the postpartum care (code 59430).
  

Note that the American College of Obstetricians and Gynecologists Coding Manual states that code 59430 includes both inpatient and outpatient postpartum care, but start until after delivery of the placenta. This means you can bill the hospital admission, but not the subsequent care or discharge home.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We recently had an obstetric patient who was admitted for observation due to upper-quadrant abdominal pain. During her stay, a general surgeon performed a cholecystectomy. She was discharged 6 days after admission, but immediately went into preterm labor, delivering at home at 27 weeks’ gestation. She and the baby were readmitted on the day after her discharge. How do I charge this?

A Did you provide all of the obstetric care except for the delivery? If so, you can bill the global obstetric service, should the payer allow, but should also add modifier -52 to indicate reduced services.

Alternatively, you may want to bill only for those services that were actually performed, by splitting the care into its component parts. This would mean billing for:

• the antepartum care using 59425 (4 to 6 visits) or 59426 (7 or more visits);
  
• the hospital admission after delivery (codes 99221-99223);
  
• the delivery of the placenta (code 59414) or an episiotomy (code 59300), if performed after the delivery; and
  
• the postpartum care (code 59430).
  

Note that the American College of Obstetricians and Gynecologists Coding Manual states that code 59430 includes both inpatient and outpatient postpartum care, but start until after delivery of the placenta. This means you can bill the hospital admission, but not the subsequent care or discharge home.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q We recently had an obstetric patient who was admitted for observation due to upper-quadrant abdominal pain. During her stay, a general surgeon performed a cholecystectomy. She was discharged 6 days after admission, but immediately went into preterm labor, delivering at home at 27 weeks’ gestation. She and the baby were readmitted on the day after her discharge. How do I charge this?

A Did you provide all of the obstetric care except for the delivery? If so, you can bill the global obstetric service, should the payer allow, but should also add modifier -52 to indicate reduced services.

Alternatively, you may want to bill only for those services that were actually performed, by splitting the care into its component parts. This would mean billing for:

• the antepartum care using 59425 (4 to 6 visits) or 59426 (7 or more visits);
  
• the hospital admission after delivery (codes 99221-99223);
  
• the delivery of the placenta (code 59414) or an episiotomy (code 59300), if performed after the delivery; and
  
• the postpartum care (code 59430).
  

Note that the American College of Obstetricians and Gynecologists Coding Manual states that code 59430 includes both inpatient and outpatient postpartum care, but start until after delivery of the placenta. This means you can bill the hospital admission, but not the subsequent care or discharge home.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Our physician performed a laparoscopically assisted vaginal hysterectomy (LAVH) and McCall’s culdoplasty. What is the McCall’s, exactly, and can we bill for it?

A McCall’s culdoplasty is a vaginal-approach repair of an enterocele (CPT 57268) and is coded only if an enterocele was present and the sac removed.

In general, an enterocele is a peritoneal sac or space between the vagina and rectum that begins to prolapse after multiple pregnancies or after a long period of time due to gravity. When the enterocele causes pain and bulging, the surgeon will remove the sac during vaginal surgery. If documentation confirms the presence of the symptomatic enterocele, the payer will likely reimburse for it. Note, however, that you’ll have to add modifier -59 (distinct procedure) to 57268, since this is a CPT “separate procedure” that the payer normally bundles.

If the surgeon sews up the cul-de-sac at the time of the LAVH to prevent a future problem, it’s considered “tidying up” and preventive and, therefore, not separately billable.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Our physician performed a laparoscopically assisted vaginal hysterectomy (LAVH) and McCall’s culdoplasty. What is the McCall’s, exactly, and can we bill for it?

A McCall’s culdoplasty is a vaginal-approach repair of an enterocele (CPT 57268) and is coded only if an enterocele was present and the sac removed.

In general, an enterocele is a peritoneal sac or space between the vagina and rectum that begins to prolapse after multiple pregnancies or after a long period of time due to gravity. When the enterocele causes pain and bulging, the surgeon will remove the sac during vaginal surgery. If documentation confirms the presence of the symptomatic enterocele, the payer will likely reimburse for it. Note, however, that you’ll have to add modifier -59 (distinct procedure) to 57268, since this is a CPT “separate procedure” that the payer normally bundles.

If the surgeon sews up the cul-de-sac at the time of the LAVH to prevent a future problem, it’s considered “tidying up” and preventive and, therefore, not separately billable.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Our physician performed a laparoscopically assisted vaginal hysterectomy (LAVH) and McCall’s culdoplasty. What is the McCall’s, exactly, and can we bill for it?

A McCall’s culdoplasty is a vaginal-approach repair of an enterocele (CPT 57268) and is coded only if an enterocele was present and the sac removed.

In general, an enterocele is a peritoneal sac or space between the vagina and rectum that begins to prolapse after multiple pregnancies or after a long period of time due to gravity. When the enterocele causes pain and bulging, the surgeon will remove the sac during vaginal surgery. If documentation confirms the presence of the symptomatic enterocele, the payer will likely reimburse for it. Note, however, that you’ll have to add modifier -59 (distinct procedure) to 57268, since this is a CPT “separate procedure” that the payer normally bundles.

If the surgeon sews up the cul-de-sac at the time of the LAVH to prevent a future problem, it’s considered “tidying up” and preventive and, therefore, not separately billable.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Which CPT codes are recommended for low-risk and high-risk Medicare pelvic/breast exams for women aged 65 and older? Are the rules the same for non-Medicare third-party payers?

A For any screening pelvic/breast exam, Medicare requires that the alphanumeric Healthcare Common Procedure Coding System code (rather than a CPT preventive medicine code) you submit be linked to a specific ICD-9 code.

For the screening, you would report G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination), regardless of whether the patient is at low or high risk for cervical or vaginal cancer. Medicare only differentiates between the risk categories via the ICD-9 diagnostic code you use.

If the patient is at low risk, use ICD-9 code V76.2 (special screening for malignant neoplasms, cervix) or V76.49 (special screening for malignant neoplasms, other sites). Effective October 1, 2003, the code V76.47 (special screening for malignant neoplasms, vagina) may also be used. Note that V76.49 (and V76.47) is used only when the patient has had her uterus removed for reasons other than malignancy. If the patient is at high risk, the diagnosis changes to V15.89 (other specified personal history presenting hazards to health), along with a second code indicating which of Medicare’s 5 high-risk criteria applies. For a woman past childbearing age (which is all patients 65 or older), these criteria are:

• early onset of sexual activity (under 16 years of age) or multiple sexual partners (5 or more in a lifetime)—use V69.2, high-risk sexual behavior;
  
• history of a sexually transmitted disease (including HIV infection)—use V13.8, personal history of other diseases; V08, asymptomatic HIV; or 042, HIV infection;
  
• fewer than 3 negative Pap smears within the previous 7 years—use the diagnosis known at the time of the last Pap smear (if normal, use the code V13.2 for personal history of genitourinary disorder to indicate a previous abnormal Pap result); and
  
• diethylstilbestrol-exposed daughters of women who took the drug during pregnancy—use 760.76 (DES exposure).
  

Non-Medicare insurers have different rules: Unlike Medicare, they tend to pay for a comprehensive well-woman exam each year, billed using 1 of the CPT preventive medicine codes (99381 to 99397). The diagnostic coding is also different—specifically V72.3, gynecologic exam with Pap smear.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Which CPT codes are recommended for low-risk and high-risk Medicare pelvic/breast exams for women aged 65 and older? Are the rules the same for non-Medicare third-party payers?

A For any screening pelvic/breast exam, Medicare requires that the alphanumeric Healthcare Common Procedure Coding System code (rather than a CPT preventive medicine code) you submit be linked to a specific ICD-9 code.

For the screening, you would report G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination), regardless of whether the patient is at low or high risk for cervical or vaginal cancer. Medicare only differentiates between the risk categories via the ICD-9 diagnostic code you use.

If the patient is at low risk, use ICD-9 code V76.2 (special screening for malignant neoplasms, cervix) or V76.49 (special screening for malignant neoplasms, other sites). Effective October 1, 2003, the code V76.47 (special screening for malignant neoplasms, vagina) may also be used. Note that V76.49 (and V76.47) is used only when the patient has had her uterus removed for reasons other than malignancy. If the patient is at high risk, the diagnosis changes to V15.89 (other specified personal history presenting hazards to health), along with a second code indicating which of Medicare’s 5 high-risk criteria applies. For a woman past childbearing age (which is all patients 65 or older), these criteria are:

• early onset of sexual activity (under 16 years of age) or multiple sexual partners (5 or more in a lifetime)—use V69.2, high-risk sexual behavior;
  
• history of a sexually transmitted disease (including HIV infection)—use V13.8, personal history of other diseases; V08, asymptomatic HIV; or 042, HIV infection;
  
• fewer than 3 negative Pap smears within the previous 7 years—use the diagnosis known at the time of the last Pap smear (if normal, use the code V13.2 for personal history of genitourinary disorder to indicate a previous abnormal Pap result); and
  
• diethylstilbestrol-exposed daughters of women who took the drug during pregnancy—use 760.76 (DES exposure).
  

Non-Medicare insurers have different rules: Unlike Medicare, they tend to pay for a comprehensive well-woman exam each year, billed using 1 of the CPT preventive medicine codes (99381 to 99397). The diagnostic coding is also different—specifically V72.3, gynecologic exam with Pap smear.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q Which CPT codes are recommended for low-risk and high-risk Medicare pelvic/breast exams for women aged 65 and older? Are the rules the same for non-Medicare third-party payers?

A For any screening pelvic/breast exam, Medicare requires that the alphanumeric Healthcare Common Procedure Coding System code (rather than a CPT preventive medicine code) you submit be linked to a specific ICD-9 code.

For the screening, you would report G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination), regardless of whether the patient is at low or high risk for cervical or vaginal cancer. Medicare only differentiates between the risk categories via the ICD-9 diagnostic code you use.

If the patient is at low risk, use ICD-9 code V76.2 (special screening for malignant neoplasms, cervix) or V76.49 (special screening for malignant neoplasms, other sites). Effective October 1, 2003, the code V76.47 (special screening for malignant neoplasms, vagina) may also be used. Note that V76.49 (and V76.47) is used only when the patient has had her uterus removed for reasons other than malignancy. If the patient is at high risk, the diagnosis changes to V15.89 (other specified personal history presenting hazards to health), along with a second code indicating which of Medicare’s 5 high-risk criteria applies. For a woman past childbearing age (which is all patients 65 or older), these criteria are:

• early onset of sexual activity (under 16 years of age) or multiple sexual partners (5 or more in a lifetime)—use V69.2, high-risk sexual behavior;
  
• history of a sexually transmitted disease (including HIV infection)—use V13.8, personal history of other diseases; V08, asymptomatic HIV; or 042, HIV infection;
  
• fewer than 3 negative Pap smears within the previous 7 years—use the diagnosis known at the time of the last Pap smear (if normal, use the code V13.2 for personal history of genitourinary disorder to indicate a previous abnormal Pap result); and
  
• diethylstilbestrol-exposed daughters of women who took the drug during pregnancy—use 760.76 (DES exposure).
  

Non-Medicare insurers have different rules: Unlike Medicare, they tend to pay for a comprehensive well-woman exam each year, billed using 1 of the CPT preventive medicine codes (99381 to 99397). The diagnostic coding is also different—specifically V72.3, gynecologic exam with Pap smear.

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-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q For laparoscopy with lysis of adhesions, peritoneal washings, peritoneal biopsies, and left ovarian excrescence removal for biopsy, should I use code 58662?

A Code 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) would cover the removal of the left ovarian excrescences, but does not capture the lysis of adhesions. Many payers bundle this procedure because they believe it is incidental. However, if the adhesions were extensive and the extra time the physician spent in removing them is well documented, you can either bill the lysis separately using code 58660-59-51 (to indicate it was a distinct, multiple procedure) or you can add modifier -22 (unusual procedure) to code 58662 to indicate extensive additional work. Note that you would only use this latter option for payers you know always bundle lysis of adhesions when billed separately (Medicare, for example).

The payer is unlikely to reimburse separately for peritoneal washings and biopsy.

Q For laparoscopy with lysis of adhesions, peritoneal washings, peritoneal biopsies, and left ovarian excrescence removal for biopsy, should I use code 58662?

A Code 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) would cover the removal of the left ovarian excrescences, but does not capture the lysis of adhesions. Many payers bundle this procedure because they believe it is incidental. However, if the adhesions were extensive and the extra time the physician spent in removing them is well documented, you can either bill the lysis separately using code 58660-59-51 (to indicate it was a distinct, multiple procedure) or you can add modifier -22 (unusual procedure) to code 58662 to indicate extensive additional work. Note that you would only use this latter option for payers you know always bundle lysis of adhesions when billed separately (Medicare, for example).

The payer is unlikely to reimburse separately for peritoneal washings and biopsy.

Q For laparoscopy with lysis of adhesions, peritoneal washings, peritoneal biopsies, and left ovarian excrescence removal for biopsy, should I use code 58662?

A Code 58662 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) would cover the removal of the left ovarian excrescences, but does not capture the lysis of adhesions. Many payers bundle this procedure because they believe it is incidental. However, if the adhesions were extensive and the extra time the physician spent in removing them is well documented, you can either bill the lysis separately using code 58660-59-51 (to indicate it was a distinct, multiple procedure) or you can add modifier -22 (unusual procedure) to code 58662 to indicate extensive additional work. Note that you would only use this latter option for payers you know always bundle lysis of adhesions when billed separately (Medicare, for example).

The payer is unlikely to reimburse separately for peritoneal washings and biopsy.

Q: How would you code a sacrospinous ligament vaginal suspension, repair of enterocele, and cystocele? This is a Medicare patient with a preoperative diagnosis of total vaginal prolapse, status post-vaginal hysterectomy with anterior and posterior repair, third-degree enterocele, and second-degree rectocele recurrent.

A: When coding any surgery for Medicare submission, it’s always a good idea to check the Correct Coding Initiative (CCI) to see which code combinations are bundled. In this case, the codes you can choose from include 57282 (for sacrospinous ligament fixation), 57240 (for cystocele repair), and 57268 (for vaginal-approach enterocele repair).

Unfortunately, CCI indicates code 57268 is not payable with code 57282. To make matters worse, you can’t bypass the edit, since this code combination is never paid. According to CCI, this is because the vaginal-approach enterocele repair is a CPT “separate procedure” and Medicare has decided that it and the sacrospinous ligament fixation are always integral to each other.

If this had been a case where a posterior repair had been done along with the anterior colporrhaphy and enterocele repair, you could have assigned code 57265 (combined antero-posterior colporrhaphy; with enterocele repair) as your second procedure, since it isn’t bundled with the sacrospinous ligament fixation procedure. You may be tempted, then, to bill code 57265 with a modifier -52 (reduced services) to get the claim paid, but I would advise against it, as this coding isn’t the most accurate description of what was done.

Instead, because there was a symptomatic enterocele that needed to be repaired, I would add a modifier -22 (unusual procedure) to code 57282 and send in supporting documentation regarding the need for the enterocele repair. Centers for Medicare & Medicaid Services staff recommended this solution a few years ago for any procedure that’s always bundled into a larger procedure, when the documentation supports performing it.

Q: How would you code a sacrospinous ligament vaginal suspension, repair of enterocele, and cystocele? This is a Medicare patient with a preoperative diagnosis of total vaginal prolapse, status post-vaginal hysterectomy with anterior and posterior repair, third-degree enterocele, and second-degree rectocele recurrent.

A: When coding any surgery for Medicare submission, it’s always a good idea to check the Correct Coding Initiative (CCI) to see which code combinations are bundled. In this case, the codes you can choose from include 57282 (for sacrospinous ligament fixation), 57240 (for cystocele repair), and 57268 (for vaginal-approach enterocele repair).

Unfortunately, CCI indicates code 57268 is not payable with code 57282. To make matters worse, you can’t bypass the edit, since this code combination is never paid. According to CCI, this is because the vaginal-approach enterocele repair is a CPT “separate procedure” and Medicare has decided that it and the sacrospinous ligament fixation are always integral to each other.

If this had been a case where a posterior repair had been done along with the anterior colporrhaphy and enterocele repair, you could have assigned code 57265 (combined antero-posterior colporrhaphy; with enterocele repair) as your second procedure, since it isn’t bundled with the sacrospinous ligament fixation procedure. You may be tempted, then, to bill code 57265 with a modifier -52 (reduced services) to get the claim paid, but I would advise against it, as this coding isn’t the most accurate description of what was done.

Instead, because there was a symptomatic enterocele that needed to be repaired, I would add a modifier -22 (unusual procedure) to code 57282 and send in supporting documentation regarding the need for the enterocele repair. Centers for Medicare & Medicaid Services staff recommended this solution a few years ago for any procedure that’s always bundled into a larger procedure, when the documentation supports performing it.

Q: How would you code a sacrospinous ligament vaginal suspension, repair of enterocele, and cystocele? This is a Medicare patient with a preoperative diagnosis of total vaginal prolapse, status post-vaginal hysterectomy with anterior and posterior repair, third-degree enterocele, and second-degree rectocele recurrent.

A: When coding any surgery for Medicare submission, it’s always a good idea to check the Correct Coding Initiative (CCI) to see which code combinations are bundled. In this case, the codes you can choose from include 57282 (for sacrospinous ligament fixation), 57240 (for cystocele repair), and 57268 (for vaginal-approach enterocele repair).

Unfortunately, CCI indicates code 57268 is not payable with code 57282. To make matters worse, you can’t bypass the edit, since this code combination is never paid. According to CCI, this is because the vaginal-approach enterocele repair is a CPT “separate procedure” and Medicare has decided that it and the sacrospinous ligament fixation are always integral to each other.

If this had been a case where a posterior repair had been done along with the anterior colporrhaphy and enterocele repair, you could have assigned code 57265 (combined antero-posterior colporrhaphy; with enterocele repair) as your second procedure, since it isn’t bundled with the sacrospinous ligament fixation procedure. You may be tempted, then, to bill code 57265 with a modifier -52 (reduced services) to get the claim paid, but I would advise against it, as this coding isn’t the most accurate description of what was done.

Instead, because there was a symptomatic enterocele that needed to be repaired, I would add a modifier -22 (unusual procedure) to code 57282 and send in supporting documentation regarding the need for the enterocele repair. Centers for Medicare & Medicaid Services staff recommended this solution a few years ago for any procedure that’s always bundled into a larger procedure, when the documentation supports performing it.