Reimbursement Advisor

ObGyns stand to benefit from new Current Procedural Terminology (CPT) codes that capture more of the specifics of procedures such as laparoscopic hysterectomy, and provide codes for newer kinds of services such as prenatal nuchal translucency screening and genetic counseling. A downside for 2007—getting accustomed to the renumbered codes for bone density and breast imaging.

Laparoscopic hysterectomy codes get specific

58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

58542 …with removal of tube(s) and/or ovary(s)

58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than
250 g

58544 …with removal of tube(s) and/or ovary(s)

Nuchal translucency: Document the detail

76813 Ultrasound, pregnant uterus, real time with image documentation, 1st-trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or 1st gestation

76814 …each additional gestation

Reimbursement should become routine for 1st-trimester nuchal translucency ultrasound imaging.

Coding has been a challenge; in fact, ACOG only recommended reporting the unlisted code 76999 (unlisted ultrasound procedure [eg, diagnostic, interventional]), which requires submission of documentation to make the case for payment. The test is normally performed between 11 and 13 weeks’ gestation.

 

When measured correctly, nuchal translucency thickness is a powerful marker in Down syndrome screening in the late first trimester

 
 

Even when the payer does not require it, documentation is important. Nuchal translucency ultrasound documentation should include:

• the fetal crown–rump length
• verification of the sagittal view of the fetal spine
• 3 measurements of the maximum thickness of the subcutaneous translucency between the skin and the soft tissue overlying the cervical spine
• as with all ultrasound procedures, image documentation and a final written report

Special training is required by the sonographer or physician who performs this measurement. So be aware that the payer may have rules to ensure such training.

Different codes for initial and recurrent cancer

58950 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy

Primary malignancy resections will continue to be reported with the existing code numbers 58950 through 58952. To make the point clear, CPT revised the wording of the base code, 58950, to specify the initial operation.

58957 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed

58958 …with pelvic lymphadenectomy

Unlike other codes for malignancy in the female genitourinary section of CPT, the above 2 new codes specify a broader range of cancers to include uterine malignancy.

Previously, code 49200 or code 49201 (excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas) would have been as reported for recurrent uterine malignancy.

Do not report these codes in addition: 38770 and 38780 (removal of pelvic or retroperitoneal lymph nodes), 44005 (enterolysis), 49000 (exploratory laparotomy), 49200–49215 (open excision of tumors), 49255 (omentectomy), or 58900–58960 (removal of tubes and ovaries).

New technologies

Uterine artery embolization

37210 Uterine artery embolization

The new code includes vascular access, vessel selection, injection of the material, intraprocedure mapping, and all radiological supervision and interpretation, including image guidance.

Genetic counseling

96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family

This code is good news for practices that use the services of a genetic counselor. Need, content, and total time must be documented in the report. However, Medicare has assigned no physician relative value units to this new code because they consider it bundled into any E/M service. Check with your payers about separate reimbursement for this service.

	OLD	NEW
BONE DENSITY
CT, bone mineral density study 1 or more sites
Axial skeleton (eg, hips, pelvis, spine)	76060	77078
Appendicular skeleton (peripheral) (eg, radius, wrist, heel)	76061	77079
Dual-energy X-ray absorptiometry, bone-density study 1 or more sites
Axial skeleton	76065	77080
Appendicular skeleton	76067	77081
Vertebral fracture assessment	76077	77082
Radiographic absorptiometry (eg, photodensitometry, radiogrammetry) 1 or more sites	76078	77083
MAMMOGRAPHY
Unilateral	76090	77055
Bilateral	76091	77056
Screening mammography, bilateral (2-view film study of each breast)	76092	77057
INTRAOPERATIVE ULTRASOUND
Ultrasound guidance, intraoperative	76986	76998

ObGyns stand to benefit from new Current Procedural Terminology (CPT) codes that capture more of the specifics of procedures such as laparoscopic hysterectomy, and provide codes for newer kinds of services such as prenatal nuchal translucency screening and genetic counseling. A downside for 2007—getting accustomed to the renumbered codes for bone density and breast imaging.

Laparoscopic hysterectomy codes get specific

58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

58542 …with removal of tube(s) and/or ovary(s)

58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than
250 g

58544 …with removal of tube(s) and/or ovary(s)

Nuchal translucency: Document the detail

76813 Ultrasound, pregnant uterus, real time with image documentation, 1st-trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or 1st gestation

76814 …each additional gestation

Reimbursement should become routine for 1st-trimester nuchal translucency ultrasound imaging.

Coding has been a challenge; in fact, ACOG only recommended reporting the unlisted code 76999 (unlisted ultrasound procedure [eg, diagnostic, interventional]), which requires submission of documentation to make the case for payment. The test is normally performed between 11 and 13 weeks’ gestation.

 

When measured correctly, nuchal translucency thickness is a powerful marker in Down syndrome screening in the late first trimester

 
 

Even when the payer does not require it, documentation is important. Nuchal translucency ultrasound documentation should include:

• the fetal crown–rump length
• verification of the sagittal view of the fetal spine
• 3 measurements of the maximum thickness of the subcutaneous translucency between the skin and the soft tissue overlying the cervical spine
• as with all ultrasound procedures, image documentation and a final written report

Special training is required by the sonographer or physician who performs this measurement. So be aware that the payer may have rules to ensure such training.

Different codes for initial and recurrent cancer

58950 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy

Primary malignancy resections will continue to be reported with the existing code numbers 58950 through 58952. To make the point clear, CPT revised the wording of the base code, 58950, to specify the initial operation.

58957 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed

58958 …with pelvic lymphadenectomy

Unlike other codes for malignancy in the female genitourinary section of CPT, the above 2 new codes specify a broader range of cancers to include uterine malignancy.

Previously, code 49200 or code 49201 (excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas) would have been as reported for recurrent uterine malignancy.

Do not report these codes in addition: 38770 and 38780 (removal of pelvic or retroperitoneal lymph nodes), 44005 (enterolysis), 49000 (exploratory laparotomy), 49200–49215 (open excision of tumors), 49255 (omentectomy), or 58900–58960 (removal of tubes and ovaries).

New technologies

Uterine artery embolization

37210 Uterine artery embolization

The new code includes vascular access, vessel selection, injection of the material, intraprocedure mapping, and all radiological supervision and interpretation, including image guidance.

Genetic counseling

96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family

This code is good news for practices that use the services of a genetic counselor. Need, content, and total time must be documented in the report. However, Medicare has assigned no physician relative value units to this new code because they consider it bundled into any E/M service. Check with your payers about separate reimbursement for this service.

	OLD	NEW
BONE DENSITY
CT, bone mineral density study 1 or more sites
Axial skeleton (eg, hips, pelvis, spine)	76060	77078
Appendicular skeleton (peripheral) (eg, radius, wrist, heel)	76061	77079
Dual-energy X-ray absorptiometry, bone-density study 1 or more sites
Axial skeleton	76065	77080
Appendicular skeleton	76067	77081
Vertebral fracture assessment	76077	77082
Radiographic absorptiometry (eg, photodensitometry, radiogrammetry) 1 or more sites	76078	77083
MAMMOGRAPHY
Unilateral	76090	77055
Bilateral	76091	77056
Screening mammography, bilateral (2-view film study of each breast)	76092	77057
INTRAOPERATIVE ULTRASOUND
Ultrasound guidance, intraoperative	76986	76998

ObGyns stand to benefit from new Current Procedural Terminology (CPT) codes that capture more of the specifics of procedures such as laparoscopic hysterectomy, and provide codes for newer kinds of services such as prenatal nuchal translucency screening and genetic counseling. A downside for 2007—getting accustomed to the renumbered codes for bone density and breast imaging.

Laparoscopic hysterectomy codes get specific

58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

58542 …with removal of tube(s) and/or ovary(s)

58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than
250 g

58544 …with removal of tube(s) and/or ovary(s)

Nuchal translucency: Document the detail

76813 Ultrasound, pregnant uterus, real time with image documentation, 1st-trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or 1st gestation

76814 …each additional gestation

Reimbursement should become routine for 1st-trimester nuchal translucency ultrasound imaging.

Coding has been a challenge; in fact, ACOG only recommended reporting the unlisted code 76999 (unlisted ultrasound procedure [eg, diagnostic, interventional]), which requires submission of documentation to make the case for payment. The test is normally performed between 11 and 13 weeks’ gestation.

 

When measured correctly, nuchal translucency thickness is a powerful marker in Down syndrome screening in the late first trimester

 
 

Even when the payer does not require it, documentation is important. Nuchal translucency ultrasound documentation should include:

• the fetal crown–rump length
• verification of the sagittal view of the fetal spine
• 3 measurements of the maximum thickness of the subcutaneous translucency between the skin and the soft tissue overlying the cervical spine
• as with all ultrasound procedures, image documentation and a final written report

Special training is required by the sonographer or physician who performs this measurement. So be aware that the payer may have rules to ensure such training.

Different codes for initial and recurrent cancer

58950 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy

Primary malignancy resections will continue to be reported with the existing code numbers 58950 through 58952. To make the point clear, CPT revised the wording of the base code, 58950, to specify the initial operation.

58957 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed

58958 …with pelvic lymphadenectomy

Unlike other codes for malignancy in the female genitourinary section of CPT, the above 2 new codes specify a broader range of cancers to include uterine malignancy.

Previously, code 49200 or code 49201 (excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas) would have been as reported for recurrent uterine malignancy.

Do not report these codes in addition: 38770 and 38780 (removal of pelvic or retroperitoneal lymph nodes), 44005 (enterolysis), 49000 (exploratory laparotomy), 49200–49215 (open excision of tumors), 49255 (omentectomy), or 58900–58960 (removal of tubes and ovaries).

New technologies

Uterine artery embolization

37210 Uterine artery embolization

The new code includes vascular access, vessel selection, injection of the material, intraprocedure mapping, and all radiological supervision and interpretation, including image guidance.

Genetic counseling

96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family

This code is good news for practices that use the services of a genetic counselor. Need, content, and total time must be documented in the report. However, Medicare has assigned no physician relative value units to this new code because they consider it bundled into any E/M service. Check with your payers about separate reimbursement for this service.

	OLD	NEW
BONE DENSITY
CT, bone mineral density study 1 or more sites
Axial skeleton (eg, hips, pelvis, spine)	76060	77078
Appendicular skeleton (peripheral) (eg, radius, wrist, heel)	76061	77079
Dual-energy X-ray absorptiometry, bone-density study 1 or more sites
Axial skeleton	76065	77080
Appendicular skeleton	76067	77081
Vertebral fracture assessment	76077	77082
Radiographic absorptiometry (eg, photodensitometry, radiogrammetry) 1 or more sites	76078	77083
MAMMOGRAPHY
Unilateral	76090	77055
Bilateral	76091	77056
Screening mammography, bilateral (2-view film study of each breast)	76092	77057
INTRAOPERATIVE ULTRASOUND
Ultrasound guidance, intraoperative	76986	76998

Q Our patient is scheduled for a cesarean delivery, but the surgeon wants to excise a large keloid scar prior to the cesarean. How should this be coded?

A I am not sure by your question of the sequence or timing of events.

If the physician is taking the patient to surgery to do only the keloid excision, you have several codes to select from, depending on the type of closure. The excision of the keloid scar would be reported using 11400–11406 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs), where the code selected depends on the documented size of the scar removed.

If it is simple closure, no additional code is reported, but if the closure is either intermediate or complex, you will add a code from the repair section (12031–12037 or 13100–13102). But again the size in centimeters must be documented in order to use these codes.

Also remember that if the surgeon performs the cesarean within 10 days of the keloid excision, he/she will be in the global period for these codes and might have to use a modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) on the global OB code you report. If the keloid is excised at the time of the cesarean, it will be included by most payers as part of establishing the operative site and incision closure.

Q Our patient is scheduled for a cesarean delivery, but the surgeon wants to excise a large keloid scar prior to the cesarean. How should this be coded?

A I am not sure by your question of the sequence or timing of events.

If the physician is taking the patient to surgery to do only the keloid excision, you have several codes to select from, depending on the type of closure. The excision of the keloid scar would be reported using 11400–11406 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs), where the code selected depends on the documented size of the scar removed.

If it is simple closure, no additional code is reported, but if the closure is either intermediate or complex, you will add a code from the repair section (12031–12037 or 13100–13102). But again the size in centimeters must be documented in order to use these codes.

Also remember that if the surgeon performs the cesarean within 10 days of the keloid excision, he/she will be in the global period for these codes and might have to use a modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) on the global OB code you report. If the keloid is excised at the time of the cesarean, it will be included by most payers as part of establishing the operative site and incision closure.

Q Our patient is scheduled for a cesarean delivery, but the surgeon wants to excise a large keloid scar prior to the cesarean. How should this be coded?

A I am not sure by your question of the sequence or timing of events.

If the physician is taking the patient to surgery to do only the keloid excision, you have several codes to select from, depending on the type of closure. The excision of the keloid scar would be reported using 11400–11406 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs), where the code selected depends on the documented size of the scar removed.

If it is simple closure, no additional code is reported, but if the closure is either intermediate or complex, you will add a code from the repair section (12031–12037 or 13100–13102). But again the size in centimeters must be documented in order to use these codes.

Also remember that if the surgeon performs the cesarean within 10 days of the keloid excision, he/she will be in the global period for these codes and might have to use a modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) on the global OB code you report. If the keloid is excised at the time of the cesarean, it will be included by most payers as part of establishing the operative site and incision closure.

Q An external cephalic version was performed on a breech baby as an outpatient procedure. I was told I could bill 01958 (Anesthesia for external cephalic version procedure) for the anesthesia, but have gotten an insurance denial because the “CPT and ICD logic do not match.” We used the diagnostic code 652.2. Are there some rules about anesthesia I should be aware of?

A There may be more than 1 problem here. First, the anesthesia codes are meant to be billed by the anesthesiologist, not the physician who is also performing the procedure. You have not indicated whether this was the case.

If you did perform the version procedure as well as providing the anesthesia to the patient, you would need to indicate this by adding a modifier -47 (Anesthesia by surgeon) to code 59412 (External cephalic version, with or without tocolysis). You would then report a 2nd code for the type of regional anesthesia you administered. For instance, if you used epidural anesthesia, you would report 59412-47, 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

If you were only providing the anesthesia, then code 01958 is correct, but now the payer is indicating a mismatch between the CPT code and the diagnosis code.

You have indicated that you used code 652.2 (Breech presentation without mention of version). But as you are billing for anesthesia for a version, this code would no longer be correct. In this case, the more correct code would be 652.13 (Breech or other malpresentation successfully converted to cephalic presentation; antepartum condition or complication) if the version was successful or 652.03 (Unstable lie; antepartum condition or complication) if it was not.

Q An external cephalic version was performed on a breech baby as an outpatient procedure. I was told I could bill 01958 (Anesthesia for external cephalic version procedure) for the anesthesia, but have gotten an insurance denial because the “CPT and ICD logic do not match.” We used the diagnostic code 652.2. Are there some rules about anesthesia I should be aware of?

A There may be more than 1 problem here. First, the anesthesia codes are meant to be billed by the anesthesiologist, not the physician who is also performing the procedure. You have not indicated whether this was the case.

If you did perform the version procedure as well as providing the anesthesia to the patient, you would need to indicate this by adding a modifier -47 (Anesthesia by surgeon) to code 59412 (External cephalic version, with or without tocolysis). You would then report a 2nd code for the type of regional anesthesia you administered. For instance, if you used epidural anesthesia, you would report 59412-47, 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

If you were only providing the anesthesia, then code 01958 is correct, but now the payer is indicating a mismatch between the CPT code and the diagnosis code.

You have indicated that you used code 652.2 (Breech presentation without mention of version). But as you are billing for anesthesia for a version, this code would no longer be correct. In this case, the more correct code would be 652.13 (Breech or other malpresentation successfully converted to cephalic presentation; antepartum condition or complication) if the version was successful or 652.03 (Unstable lie; antepartum condition or complication) if it was not.

Q An external cephalic version was performed on a breech baby as an outpatient procedure. I was told I could bill 01958 (Anesthesia for external cephalic version procedure) for the anesthesia, but have gotten an insurance denial because the “CPT and ICD logic do not match.” We used the diagnostic code 652.2. Are there some rules about anesthesia I should be aware of?

A There may be more than 1 problem here. First, the anesthesia codes are meant to be billed by the anesthesiologist, not the physician who is also performing the procedure. You have not indicated whether this was the case.

If you did perform the version procedure as well as providing the anesthesia to the patient, you would need to indicate this by adding a modifier -47 (Anesthesia by surgeon) to code 59412 (External cephalic version, with or without tocolysis). You would then report a 2nd code for the type of regional anesthesia you administered. For instance, if you used epidural anesthesia, you would report 59412-47, 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

If you were only providing the anesthesia, then code 01958 is correct, but now the payer is indicating a mismatch between the CPT code and the diagnosis code.

You have indicated that you used code 652.2 (Breech presentation without mention of version). But as you are billing for anesthesia for a version, this code would no longer be correct. In this case, the more correct code would be 652.13 (Breech or other malpresentation successfully converted to cephalic presentation; antepartum condition or complication) if the version was successful or 652.03 (Unstable lie; antepartum condition or complication) if it was not.

Q We plan to perform a laparoscopic right salpingo-oophorectomy and laparoscopic removal of the cervix. The patient had a previous laparoscopic supracervical hysterectomy and is now having abnormal bleeding and right lower quadrant pain. I know that the code for the RSO is 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]), but how should we report the removal of the cervix?

A Although there is a CPT code for a trachelectomy (57530, Trachelectomy [cervicectomy], amputation of cervix [separate procedure]), this code cannot be reported because the procedure was performed laparoscopically. CPT rules dictate that correct coding would be an unlisted laparoscopic code.

2 options

This leaves you with 2 coding options. Because the cervix is part of the uterus, the code 58578 (Unlisted laparoscopy procedure, uterus) would be appropriate. If you choose this option, you would report 58661, 58578-51. Alternatively, you could add a modifier -22 (Unusual procedural services) to code 58661. Whichever option you choose, you will need to send documentation with the claim to explain the unlisted procedure or the additional work.

I prefer the first option because it will give you the opportunity to set your fee to account for the actual work performed.

Most payers will not deny unlisted procedures so long as they are not considered investigational or experimental, a concept that should not apply to this surgery.

Q We plan to perform a laparoscopic right salpingo-oophorectomy and laparoscopic removal of the cervix. The patient had a previous laparoscopic supracervical hysterectomy and is now having abnormal bleeding and right lower quadrant pain. I know that the code for the RSO is 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]), but how should we report the removal of the cervix?

A Although there is a CPT code for a trachelectomy (57530, Trachelectomy [cervicectomy], amputation of cervix [separate procedure]), this code cannot be reported because the procedure was performed laparoscopically. CPT rules dictate that correct coding would be an unlisted laparoscopic code.

2 options

This leaves you with 2 coding options. Because the cervix is part of the uterus, the code 58578 (Unlisted laparoscopy procedure, uterus) would be appropriate. If you choose this option, you would report 58661, 58578-51. Alternatively, you could add a modifier -22 (Unusual procedural services) to code 58661. Whichever option you choose, you will need to send documentation with the claim to explain the unlisted procedure or the additional work.

I prefer the first option because it will give you the opportunity to set your fee to account for the actual work performed.

Most payers will not deny unlisted procedures so long as they are not considered investigational or experimental, a concept that should not apply to this surgery.

Q We plan to perform a laparoscopic right salpingo-oophorectomy and laparoscopic removal of the cervix. The patient had a previous laparoscopic supracervical hysterectomy and is now having abnormal bleeding and right lower quadrant pain. I know that the code for the RSO is 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]), but how should we report the removal of the cervix?

A Although there is a CPT code for a trachelectomy (57530, Trachelectomy [cervicectomy], amputation of cervix [separate procedure]), this code cannot be reported because the procedure was performed laparoscopically. CPT rules dictate that correct coding would be an unlisted laparoscopic code.

2 options

This leaves you with 2 coding options. Because the cervix is part of the uterus, the code 58578 (Unlisted laparoscopy procedure, uterus) would be appropriate. If you choose this option, you would report 58661, 58578-51. Alternatively, you could add a modifier -22 (Unusual procedural services) to code 58661. Whichever option you choose, you will need to send documentation with the claim to explain the unlisted procedure or the additional work.

I prefer the first option because it will give you the opportunity to set your fee to account for the actual work performed.

Most payers will not deny unlisted procedures so long as they are not considered investigational or experimental, a concept that should not apply to this surgery.

Q During a sling procedure for stress urinary incontinence, the surgeon accidentally knicked the bladder, which was then repaired, and a cystoscopy was also performed. These procedures were denied as included in the sling procedure. This was a Medicare patient.

A Unfortunately, your coding ran afoul of established National Correct Coding Initiative (NCCI) bundling and general guidelines.

I assume that you appropriately used the ICD-9-CM code 998.2 (Accidental puncture or laceration during a procedure) when billing for the suture of the bladder (51860, Cystorrhaphy, suture of bladder wound, injury or rupture; simple or 51865,.......; complicated).

Although neither of these codes is bundled with the sling procedure (57288, Sling operation for stress incontinence [eg, fascia or synthetic]), the general rules for NCCI state: “When a complication described by codes defining complications arises during an operative session, a separate service for treating the complication is not to be reported.” The use of the complication diagnosis would trigger the denial.

In addition, you apparently billed code 52000 (Cystourethroscopy [separate procedure]), and this code is bundled into code 57288 with a “0” indicator, which means that the edit cannot be bypassed using any modifier.

The good news

These rules would only apply to Medicare or to payers who use Medicare rules. Although you may find that 52000 may be a common bundle by many payers, you will not usually find commercial insurance denying the repair of the complication during surgery.

Q During a sling procedure for stress urinary incontinence, the surgeon accidentally knicked the bladder, which was then repaired, and a cystoscopy was also performed. These procedures were denied as included in the sling procedure. This was a Medicare patient.

A Unfortunately, your coding ran afoul of established National Correct Coding Initiative (NCCI) bundling and general guidelines.

I assume that you appropriately used the ICD-9-CM code 998.2 (Accidental puncture or laceration during a procedure) when billing for the suture of the bladder (51860, Cystorrhaphy, suture of bladder wound, injury or rupture; simple or 51865,.......; complicated).

Although neither of these codes is bundled with the sling procedure (57288, Sling operation for stress incontinence [eg, fascia or synthetic]), the general rules for NCCI state: “When a complication described by codes defining complications arises during an operative session, a separate service for treating the complication is not to be reported.” The use of the complication diagnosis would trigger the denial.

In addition, you apparently billed code 52000 (Cystourethroscopy [separate procedure]), and this code is bundled into code 57288 with a “0” indicator, which means that the edit cannot be bypassed using any modifier.

The good news

These rules would only apply to Medicare or to payers who use Medicare rules. Although you may find that 52000 may be a common bundle by many payers, you will not usually find commercial insurance denying the repair of the complication during surgery.

Q During a sling procedure for stress urinary incontinence, the surgeon accidentally knicked the bladder, which was then repaired, and a cystoscopy was also performed. These procedures were denied as included in the sling procedure. This was a Medicare patient.

A Unfortunately, your coding ran afoul of established National Correct Coding Initiative (NCCI) bundling and general guidelines.

I assume that you appropriately used the ICD-9-CM code 998.2 (Accidental puncture or laceration during a procedure) when billing for the suture of the bladder (51860, Cystorrhaphy, suture of bladder wound, injury or rupture; simple or 51865,.......; complicated).

Although neither of these codes is bundled with the sling procedure (57288, Sling operation for stress incontinence [eg, fascia or synthetic]), the general rules for NCCI state: “When a complication described by codes defining complications arises during an operative session, a separate service for treating the complication is not to be reported.” The use of the complication diagnosis would trigger the denial.

In addition, you apparently billed code 52000 (Cystourethroscopy [separate procedure]), and this code is bundled into code 57288 with a “0” indicator, which means that the edit cannot be bypassed using any modifier.

The good news

These rules would only apply to Medicare or to payers who use Medicare rules. Although you may find that 52000 may be a common bundle by many payers, you will not usually find commercial insurance denying the repair of the complication during surgery.

Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Are you monitoring a pregnant patient who had gastric banding or stapling?

There’s a code for that, as of Oct. 1.

Have you seen female genital cutting or mutilation in your practice?

There is a code for that.

Has your patient’s obesity made it difficult to obtain a diagnostic image?

You get the picture.

The new International Diagnostic Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) adds specific codes for these and other disorders.

Cancer codes clinch the case

Specific codes now describe findings that indicate a cancer diagnosis and support appropriate treatment.

Estrogen receptor status

V86.0 Estrogen receptor positive

V86.1 Estrogen receptor negative

The 2007 ICD-9-CM adds a new category: estrogen receptor status. This bit of diagnostic information is an important indicator of the type of treatment to which breast cancer will be responsive. For instance, an estrogen-receptor–positive (ER+) finding means estrogen is causing the tumor to grow. This information in conjunction with a primary diagnosis of malignant neoplasm of the breast (ICD-9-CM codes 174.0–174.9) instantly gives the payer a snapshot of the patient’s condition and supports hormone suppression treatment.

Elevated tumor markers

795.81 Elevated carcinoembryonic antigen [CEA]

795.82 Elevated cancer antigen 125 [CA 125]

795.89 Other abnormal tumor markers

Previously, an elevated CA-125 tumor marker was reported using the unspecified code 790.99 (other nonspecific findings in blood), but with the addition of a new code subcategory, 795.8x, to report elevated tumor-associated and specific antigens, this will no longer be a problem.

Abnormal cervical cytology

795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy

The inclusion term “cytologic evidence of carcinoma” was deleted from code 795.04 (Papanicolaou smear of cervix and cervical HPV). A new code reports this finding, and this new code is now an “excludes” diagnosis under code 233.1 (carcinoma in situ of cervix uteri). Furthermore, code 233.1 has a new inclusion definition: cervical intraepithelial glandular neoplasia.

OB complications

649.xx Other conditions or status of the mother, complicating pregnancy, childbirth, or the puerperium

Preexisting conditions are covered in the new category.

Bariatric surgery and pregnancy

649.2X Bariatric surgery status complicating pregnancy, childbirth, or the puerperium

Until now, if you were monitoring a pregnant woman more closely because of her previous bariatric surgery, your only option was code 648.93 (other current conditions, classifiable elsewhere). The new code is for any intervention required during the pregnancy, if the mother has had obesity surgery such as gastric banding or gastric stapling.

A 5th digit must be appended: 0, unspecified episode of care; 1, delivered with or without mention of antepartum condition; 2, delivered with postpartum condition; 3, antepartum condition or complication; 4, postpartum complication.

Smoking, obesity, epilepsy, and more

649.0 [0–4] Tobacco use disorder

You must clearly indicate that the patient’s current smoking is complicating the management of her pregnancy.

649.1 [0–4] Obesity

A secondary code for type of obesity is required; for instance, 278.01 (morbid obesity).

649.3 [0–4] Coagulation defects

A second code from the 286 category (coagulation defects) must be added to identify the exact condition. If a coagulation defect causes antepartum hemorrhage, the correct code is 641.3x. A coagulation defect that appears only in the postpartum period is coded 666.3x.

649.4 [0–4] Epilepsy

A secondary code identifies the type of epilepsy (345.00–345.91). However, if the patient has eclampsia, use the code 642.6 (eclampsia with convulsions).

649.5 [0, 1, 3] Spotting

This code will be used predominately in early pregnancy when spotting is the chief complaint and there is no evidence of miscarriage. Note that the allowable 5th digits for this code exclude 2 and 4, because spotting is not considered a complication in the postpartum period. If the patient is bleeding heavily, other existing codes would be selected, such as 640.0x (threatened abortion) or 641.1x (hemorrhage from placenta previa).

649.6 [0–4] Uterine size-date discrepancy

This condition, which was formerly included under 646.8x (other specified complications of pregnancy), is used most often when an ultrasound is performed to date the pregnancy, especially when the last monthly period is unknown.

666.1x Other immediate postpartum hemorrhage

This code is revised, and now specifies uterine atony with hemorrhage. Uterine atony without hemorrhage is coded 669.8x.

More specific “other” codes

Several “other”-type codes for gynecologic conditions got more specific. For example, 2 new, more specific, 5-digit codes replace code 616.8 (other specified inflammatory diseases of cervix, vagina, and vulva).

 

616.81 Mucositis (ulcerative) of the cervix, vagina, and vulva

Requires an additional E code to identify the adverse affects of therapy that caused the mucositis, such as antineoplastic or immunosuppressive drugs or radiation therapy.

616.89 Other inflammatory disease of the cervix, vagina, and vulva

Identifies conditions such as a caruncle of the vagina or labium or ulcer of the vagina.

616.84 Cervical stump prolapse

Previously was reported with the code 618.39 (other specified genital prolapse).

629.29 Other types of female genital mutilation

This code includes female genital cutting or mutilation Type IV status, the collective term for other types of mutilation that can include such things as pricking the clitoris with needles, burning or scarring the genitals, and ripping or tearing the vagina.

Code 629.8 (other specified disorders of female genital organs) was deleted and replaced by these 2 new 5-digit codes:

629.81 Habitual aborter without current pregnancy

629.89 Other unspecified disorders of female genital organs

Index changes to ICD-9-CM are also important to note. This year the reference for vaginal intraepithelial neoplasia (VIN I and VIN II) was changed from code 624.8 (other specified noninflammatory disorders of vulva and perineum) to:

624.0 Dystrophy of vulva

New category: Pain control

338 Pain, not elsewhere classified

338.18 Other acute postoperative pain

338.28 Other chronic postoperative pain

338.3 Neoplasm-related pain (acute) (chronic)

Diagnostic coding just got easier if your practice includes insertion of an On-Q device for postoperative pain. A whole new category of codes groups pain into acute and chronic classifications and includes codes for both types of postoperative pain. These new codes would not be used to report generalized pain (780.96) or localized pain by site (eg, pelvic pain, 625.9), or pain disorders attributed to psychological factors. Listed above are some of the new codes in this category that may be of particular interest to ObGyns.

Imaging

Breast calcifications

793.81 Microcalcifications seen on a mammogram

793.89 Other abnormal findings on radiological examination of breast

ICD-9-CM now differentiates microcalcifications. The less-specific code is for findings documented as simply mammographic calcification or mammographic calculus.

Inconclusive imaging due to obesity

793.91 Image test inconclusive due to excess body fat

You must add a second code indicating the patient’s body mass index (BMI).

Other imaging abnormalities

793.99 Other nonspecific abnormal findings on radiological and other examination of body structure

This code could be reported for such things as an abnormal placental finding on ultrasound or an abnormal finding in the skin or subcutaneous tissue, where a more definitive diagnosis is not available.

Urinary symptoms

Additions to your diagnostic arsenal:

788.64 Urinary hesitancy

788.65 Straining on urination

Hyperglycemia

A new inclusion term is added

790.29 Other abnormal glucose

The existing code now includes a diagnosis of hyperglycemia not elsewhere specified.

V-codes for men

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of habitual aborter

V26.39 Other genetic testing of male

Use these new codes to identify the male as the reason for doing the testing—something that has been lacking for years.

Q I performed a resection of a submucous fibroid and also did uterine curettage. I will report code 58561 (Hysteroscopy, surgical; with removal of leiomyomata) for the primary procedure, but can I also bill for the curettage?

A Yes. Code 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) is not bundled with code 58561 under the National Correct Coding Initiative (NCCI). But to avoid denial you must establish medical justification for doing the curettage by indicating a diagnosis other than submucous fibroid (218.0).

Q I performed a resection of a submucous fibroid and also did uterine curettage. I will report code 58561 (Hysteroscopy, surgical; with removal of leiomyomata) for the primary procedure, but can I also bill for the curettage?

A Yes. Code 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) is not bundled with code 58561 under the National Correct Coding Initiative (NCCI). But to avoid denial you must establish medical justification for doing the curettage by indicating a diagnosis other than submucous fibroid (218.0).

Q I performed a resection of a submucous fibroid and also did uterine curettage. I will report code 58561 (Hysteroscopy, surgical; with removal of leiomyomata) for the primary procedure, but can I also bill for the curettage?

A Yes. Code 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) is not bundled with code 58561 under the National Correct Coding Initiative (NCCI). But to avoid denial you must establish medical justification for doing the curettage by indicating a diagnosis other than submucous fibroid (218.0).

Q How do you code a positive test for human papillomavirus high-risk DNA (795.05) in a pregnant patient?

A The most accurate code for this finding would be 647.63 (Other viral diseases). This code includes conditions classifiable to HPV. Your secondary diagnosis will be 795.05.

Q How do you code a positive test for human papillomavirus high-risk DNA (795.05) in a pregnant patient?

A The most accurate code for this finding would be 647.63 (Other viral diseases). This code includes conditions classifiable to HPV. Your secondary diagnosis will be 795.05.

Q How do you code a positive test for human papillomavirus high-risk DNA (795.05) in a pregnant patient?

A The most accurate code for this finding would be 647.63 (Other viral diseases). This code includes conditions classifiable to HPV. Your secondary diagnosis will be 795.05.

Q We perform diagnostic and operative hysteroscopy in our office. How do we recoup our loss compared with the hospital? Can we bill a separate physician and technical component?

A The Medicare Resource-Based Relative Value Scale (RBRVS) normally allows a practice expense increase for procedures that may be performed in the office and require expensive equipment, but are more typically performed in the hospital. The Medicare Relative Value Unit (RVU) is 9.42 for code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). For hysteroscopy procedures, there is no difference in the RVU for site of service—with 3 exceptions:

• Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
  
• Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
  
• Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
  

The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.

Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.

Q We perform diagnostic and operative hysteroscopy in our office. How do we recoup our loss compared with the hospital? Can we bill a separate physician and technical component?

A The Medicare Resource-Based Relative Value Scale (RBRVS) normally allows a practice expense increase for procedures that may be performed in the office and require expensive equipment, but are more typically performed in the hospital. The Medicare Relative Value Unit (RVU) is 9.42 for code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). For hysteroscopy procedures, there is no difference in the RVU for site of service—with 3 exceptions:

• Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
  
• Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
  
• Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
  

The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.

Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.

Q We perform diagnostic and operative hysteroscopy in our office. How do we recoup our loss compared with the hospital? Can we bill a separate physician and technical component?

A The Medicare Resource-Based Relative Value Scale (RBRVS) normally allows a practice expense increase for procedures that may be performed in the office and require expensive equipment, but are more typically performed in the hospital. The Medicare Relative Value Unit (RVU) is 9.42 for code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). For hysteroscopy procedures, there is no difference in the RVU for site of service—with 3 exceptions:

• Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
  
• Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
  
• Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
  

The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.

Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

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

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

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

Q What CPT code should I use for marsupialization of Gartner’s duct cyst?

A If the cyst was excised, code 57135 (excision of vaginal cyst or tumor), is appropriate.

But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).

The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.

Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.

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