Reimbursement Advisor

Q When a patient is scanned during the third trimester for indications such as advanced maternal age, pregnancy-induced hypertension, a large-for-gestational-age fetus, oligohydramnios, or shortened cervix, which code should I use: 76811, 76815, or 76816?

A Your choice of code will depend on what was documented previously and which elements of the scan are being documented at the present time. (I am assuming there was an initial scan, usually reported using codes 76801-76810)

Use code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) only when all of its elements are performed. If you are scanning for 1 or more of the conditions you have listed but not performing all the elements included in 76811, your coding choice is either 76815 (ultrasound, pregnant uterus, real time with image documentation, limited) or 76816 (ultrasound, pregnant uterus, real time with image documentation, follow-up…, transabdominal approach, per fetus).

It all boils down to what was known before this scan was ordered. If 1 or more of the conditions you listed were discovered at the time of a previous scan and now require ongoing monitoring, use code 76816. If 1 or more of the conditions mentioned are only now in evidence, use code 76815.

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 When a patient is scanned during the third trimester for indications such as advanced maternal age, pregnancy-induced hypertension, a large-for-gestational-age fetus, oligohydramnios, or shortened cervix, which code should I use: 76811, 76815, or 76816?

A Your choice of code will depend on what was documented previously and which elements of the scan are being documented at the present time. (I am assuming there was an initial scan, usually reported using codes 76801-76810)

Use code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) only when all of its elements are performed. If you are scanning for 1 or more of the conditions you have listed but not performing all the elements included in 76811, your coding choice is either 76815 (ultrasound, pregnant uterus, real time with image documentation, limited) or 76816 (ultrasound, pregnant uterus, real time with image documentation, follow-up…, transabdominal approach, per fetus).

It all boils down to what was known before this scan was ordered. If 1 or more of the conditions you listed were discovered at the time of a previous scan and now require ongoing monitoring, use code 76816. If 1 or more of the conditions mentioned are only now in evidence, use code 76815.

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 When a patient is scanned during the third trimester for indications such as advanced maternal age, pregnancy-induced hypertension, a large-for-gestational-age fetus, oligohydramnios, or shortened cervix, which code should I use: 76811, 76815, or 76816?

A Your choice of code will depend on what was documented previously and which elements of the scan are being documented at the present time. (I am assuming there was an initial scan, usually reported using codes 76801-76810)

Use code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) only when all of its elements are performed. If you are scanning for 1 or more of the conditions you have listed but not performing all the elements included in 76811, your coding choice is either 76815 (ultrasound, pregnant uterus, real time with image documentation, limited) or 76816 (ultrasound, pregnant uterus, real time with image documentation, follow-up…, transabdominal approach, per fetus).

It all boils down to what was known before this scan was ordered. If 1 or more of the conditions you listed were discovered at the time of a previous scan and now require ongoing monitoring, use code 76816. If 1 or more of the conditions mentioned are only now in evidence, use code 76815.

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 Are CPT 76805 and 76811 different? Both are for fetal and maternal ultrasound evaluation, yet 76811 includes a detailed fetal anatomic exam. Our ultrasonographer says she always does a detailed fetal exam.

A Code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus a detailed fetal anatomic examination, transabdominal approach; single or first gestation) requires both basic examination of fetal and maternal structures included with code 76805 (determination of number of fetuses and amniotic/chorionic sacs; measurements appropriate for gestational age; survey of intracranial, spinal, and abdominal anatomy; 4-chambered heart; umbilical cord insertion site; placenta location; amniotic fluid assessment; and maternal adnexa), and a detailed examination of fetal anatomy. This includes evaluation of fetal brain and ventricles; face; heart and outflow tracts and chest anatomy; abdominal organ-specific anatomy; number, length, and architecture of limbs; and detailed evaluation of the umbilical cord, placenta, and other fetal anatomy that may be clinically indicated.

Smaller, office ultrasound machines cannot perform this detailed exam. Larger, more sophisticated machines found in radiology departments are required; some maternal-fetal specialists’ offices also have such equipment. A detailed examination is not warranted in every case just because the required machine is handy. The key to use of code 76811 is medical justification (eg, a suspected fetal problem).

Q If a patient is scanned both transvaginally and transabdominally in the first trimester, can I use both code 76801 and code 76817?

A Since the first trimester encompasses pregnancy through 14 weeks’ gestation (equal to 14 weeks, 0 days), check the patient record for gestation on the date of the scan to be sure. If the patient is less than 14 weeks, 0 days of gestation, and the documentation shows both a fetal and maternal evaluation, the correct code would be 76801 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [

Make sure that there are 2 reports—1 for the abdominal and 1 for the vaginal scan—and that both are medically indicated. Also, since you are doing multiple scans in 1 encounter, add a modifier-51 (multiple procedure) to the code with the lower relative value.

Which code takes modifier-51? It depends on whether you bill for the professional and technical components (you own the machine) or just the professional part (physician provides the interpretation and report only), because the 3 relative-value components assigned to each code add up differently.

If you bill the complete service, use 76817, 76801-51. If you bill for the professional component only (which means you need to add the modifier -26 to both codes), the reverse is true: Use codes 76801-26, 76817-26-51.

Q Are CPT 76805 and 76811 different? Both are for fetal and maternal ultrasound evaluation, yet 76811 includes a detailed fetal anatomic exam. Our ultrasonographer says she always does a detailed fetal exam.

A Code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus a detailed fetal anatomic examination, transabdominal approach; single or first gestation) requires both basic examination of fetal and maternal structures included with code 76805 (determination of number of fetuses and amniotic/chorionic sacs; measurements appropriate for gestational age; survey of intracranial, spinal, and abdominal anatomy; 4-chambered heart; umbilical cord insertion site; placenta location; amniotic fluid assessment; and maternal adnexa), and a detailed examination of fetal anatomy. This includes evaluation of fetal brain and ventricles; face; heart and outflow tracts and chest anatomy; abdominal organ-specific anatomy; number, length, and architecture of limbs; and detailed evaluation of the umbilical cord, placenta, and other fetal anatomy that may be clinically indicated.

Smaller, office ultrasound machines cannot perform this detailed exam. Larger, more sophisticated machines found in radiology departments are required; some maternal-fetal specialists’ offices also have such equipment. A detailed examination is not warranted in every case just because the required machine is handy. The key to use of code 76811 is medical justification (eg, a suspected fetal problem).

Q If a patient is scanned both transvaginally and transabdominally in the first trimester, can I use both code 76801 and code 76817?

A Since the first trimester encompasses pregnancy through 14 weeks’ gestation (equal to 14 weeks, 0 days), check the patient record for gestation on the date of the scan to be sure. If the patient is less than 14 weeks, 0 days of gestation, and the documentation shows both a fetal and maternal evaluation, the correct code would be 76801 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [

Make sure that there are 2 reports—1 for the abdominal and 1 for the vaginal scan—and that both are medically indicated. Also, since you are doing multiple scans in 1 encounter, add a modifier-51 (multiple procedure) to the code with the lower relative value.

Which code takes modifier-51? It depends on whether you bill for the professional and technical components (you own the machine) or just the professional part (physician provides the interpretation and report only), because the 3 relative-value components assigned to each code add up differently.

If you bill the complete service, use 76817, 76801-51. If you bill for the professional component only (which means you need to add the modifier -26 to both codes), the reverse is true: Use codes 76801-26, 76817-26-51.

Q Are CPT 76805 and 76811 different? Both are for fetal and maternal ultrasound evaluation, yet 76811 includes a detailed fetal anatomic exam. Our ultrasonographer says she always does a detailed fetal exam.

A Code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus a detailed fetal anatomic examination, transabdominal approach; single or first gestation) requires both basic examination of fetal and maternal structures included with code 76805 (determination of number of fetuses and amniotic/chorionic sacs; measurements appropriate for gestational age; survey of intracranial, spinal, and abdominal anatomy; 4-chambered heart; umbilical cord insertion site; placenta location; amniotic fluid assessment; and maternal adnexa), and a detailed examination of fetal anatomy. This includes evaluation of fetal brain and ventricles; face; heart and outflow tracts and chest anatomy; abdominal organ-specific anatomy; number, length, and architecture of limbs; and detailed evaluation of the umbilical cord, placenta, and other fetal anatomy that may be clinically indicated.

Smaller, office ultrasound machines cannot perform this detailed exam. Larger, more sophisticated machines found in radiology departments are required; some maternal-fetal specialists’ offices also have such equipment. A detailed examination is not warranted in every case just because the required machine is handy. The key to use of code 76811 is medical justification (eg, a suspected fetal problem).

Q If a patient is scanned both transvaginally and transabdominally in the first trimester, can I use both code 76801 and code 76817?

A Since the first trimester encompasses pregnancy through 14 weeks’ gestation (equal to 14 weeks, 0 days), check the patient record for gestation on the date of the scan to be sure. If the patient is less than 14 weeks, 0 days of gestation, and the documentation shows both a fetal and maternal evaluation, the correct code would be 76801 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [

Make sure that there are 2 reports—1 for the abdominal and 1 for the vaginal scan—and that both are medically indicated. Also, since you are doing multiple scans in 1 encounter, add a modifier-51 (multiple procedure) to the code with the lower relative value.

Which code takes modifier-51? It depends on whether you bill for the professional and technical components (you own the machine) or just the professional part (physician provides the interpretation and report only), because the 3 relative-value components assigned to each code add up differently.

If you bill the complete service, use 76817, 76801-51. If you bill for the professional component only (which means you need to add the modifier -26 to both codes), the reverse is true: Use codes 76801-26, 76817-26-51.

Q Our doctor performed an endometrial cryoablation with ultrasonic guidance (code 0009T). The hospital tech performed the ultrasound, while our doctor supervised. Do we still charge for the global component of 0009T?

A Actually, for the Category III code 0009T, I am not sure anyone thought about creating a professional and technical component, since ultrasonic guidance is integral to the procedure.

So long as the physician supervised the procedure, I would bill the code with no modifiers attached. The hospital can bill separately for the use of the machine and the hospital tech.

Q Our doctor performed an endometrial cryoablation with ultrasonic guidance (code 0009T). The hospital tech performed the ultrasound, while our doctor supervised. Do we still charge for the global component of 0009T?

A Actually, for the Category III code 0009T, I am not sure anyone thought about creating a professional and technical component, since ultrasonic guidance is integral to the procedure.

So long as the physician supervised the procedure, I would bill the code with no modifiers attached. The hospital can bill separately for the use of the machine and the hospital tech.

Q Our doctor performed an endometrial cryoablation with ultrasonic guidance (code 0009T). The hospital tech performed the ultrasound, while our doctor supervised. Do we still charge for the global component of 0009T?

A Actually, for the Category III code 0009T, I am not sure anyone thought about creating a professional and technical component, since ultrasonic guidance is integral to the procedure.

So long as the physician supervised the procedure, I would bill the code with no modifiers attached. The hospital can bill separately for the use of the machine and the hospital tech.

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.