# Coding question....help!



## lorilog (Dec 13, 2010)

Got this question today from a provider within my organization.  I'm not real skilled with OB/GYN coding.  Do any of you know how this should be coded?   Any help is appreciated! 

I took a patient to the OR intending to due a uterine dilation, curettage, diagnostic hysteroscopy.  I performed an exam under anestheisa, dilated the external cervical os and performed hysteroscopy of cervix hoping to locate and dilate internal os, but due to stenotic internal os and anatomical distortion due to large fibroids, I could not visualize or sample the endometrial cavity.  How do I code this?

Lori


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## btadlock1 (Dec 13, 2010)

lorilog said:


> Got this question today from a provider within my organization.  I'm not real skilled with OB/GYN coding.  Do any of you know how this should be coded?   Any help is appreciated!
> 
> I took a patient to the OR intending to due a uterine dilation, curettage, diagnostic hysteroscopy.  I performed an exam under anestheisa, dilated the external cervical os and performed hysteroscopy of cervix hoping to locate and dilate internal os, but due to stenotic internal os and anatomical distortion due to large fibroids, I could not visualize or sample the endometrial cavity.  How do I code this?
> 
> Lori



58558/53, and I would include 622.4 & 622.8 after the primary diagnosis (indication for the procedure). Would that work?


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## preserene (Dec 13, 2010)

For the diagnosis code I would like to give 218.9, 622.4  and a Vcode V64.1 or 64.3 .
FIBROID UETRUS is the underlying cause for the obstruction or stenosis.


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## btadlock1 (Dec 13, 2010)

*Question...*



preserene said:


> For the diagnosis code I would like to give 218.9, 622.4  and a Vcode V64.1 or 64.3 .
> FIBROID UETRUS is the underlying cause for the obstruction or stenosis.




Whenever fibroids are mentioned, is it assumed that they are uterine? I wouldn't have selected a code with a mention of uterine fibroids, because the op note just said that there was anatomical distortion due to large fibroids - it didn't really say where the fibroids were, but it said that the doctor _had been *hoping*_ to locate the internal os to dialate it, but wasn't able to carry out the plan, so I took that as they never saw the inside of the uterus.

I personally don't think there's enough info provided to assign a definitive primary diagnosis - it never really says what the doctor was looking to confirm or rule out by doing the procedure. The guidelines say that when the original treatment plan is not carried out, you code the condition which necessitated the treatment first, even though it wasn't carried out due to unforseen circumstances. I agree with the V-code, but I'd stick with V64.1, because I tend to think of V64.3 as applicable to things like "there was no OR available" or something like that. 

I should explain - I'm not arguing for the sake of arguing, or because I think I'm right - it's just how I learn - I have to explain my thought process so I can pinpoint where I went wrong, so what looks like an argument is actually a request for constructive criticism - I need to know why I didn't get the same answer as you, and this is the only way I know how...If I come across as being defensive, or a know-it-all, I'm* seriously *not trying to - it's hard to guess someone's intentions through writing, though, so I know I'm often misunderstood and come across like a jerk...


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## lorilog (Dec 13, 2010)

*Thanks*

Thank you to both of you!  I think the doc only really needed the CPT code anyhow, so no worries.  I appreciate your expertise and time.


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## preserene (Dec 13, 2010)

Hi Btadlock1, as I said earlier I like the way and the swift and intelligent thoughts you bring forth is very pleasing and encouraging. I honestly say so. It is a thought process for each one of us and we improve our knowledge mutually. that is the best part of it.
Well regarding the Fibroid uterus, that large fibroid in this scenario, could be from the lower uterus or from the cervix uteri or even a broad ligament Fibroid. It is commonly the cervical/broad ligament one that occludes so much the cervical canal-a sort of mechanical occlusion.
I agree with you for V for 64.1 to be more closer.
Thank you  very much, both of you for your input.


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## bonzaibex (Dec 14, 2010)

Modifier Clarification:  I would use modifier 52 in this case, not 53.  Here's some info I've saved from one of my newsletters regarding a failed IUD insert--I think their IUD secenario advice can be applied to your failed procedure:

"CPT Assistant December 1996 explains you should use modifier 53 when a patient experiences an unexpected response or life-threatening condition that causes the procedure to be terminated (such as the patient fainting or developing an arrhythmia)......Payers will reduce the allowable when this modifier is appended. For instance, Tufts Health Plan will reimburse only 20 percent of the allowable amount, while Harvard Pilgrim will allow 50 percent of the allowable......Unlike modifier 53, modifier 52 implies the physician did at least some of the work involved in doing the procedure. In most cases, the amount of the reduction is dependent on documentation showing how much work was involved. In some cases, if the insertion attempt involved more significant work than normal placement, no reduction in payment will occur. For instance, in this case, the patient had a false track, but many insertions that involve cervical stenosis can be equally as difficult. Tufts indicates you would receive 70 percent or more of the allowable when you report a modifier 52."

Becky, CPC


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## lorilog (Dec 14, 2010)

*52/53 modifier*

Thank you Becky.  I'm glad you pointed that out.  I found an article online regarding those two modifiers, and I agree with you.  Here is what I found -

If the ob/gyn stops the procedure because it is endangering the welfare of the patient, append modifier -53 (discontinued procedure). But if he or she is not able to complete the procedure for other reasons, such as the anatomy of the patient, append modifier -52 (reduced services). Use a -52 for an incomplete procedure and a -53 for a canceled procedure, explains Susan Callaway-Stradley, CPC, an independent coding consultant.

The distinguishing difference between modifiers -52 and -53 is that -52 reflects it was the ob/gyn who could not complete the procedure as it is outlined in the CPT, while -53 indicates the procedure was started but had to be stopped because the patient experienced unexpected responses.

Those are two modifiers that can be so confusing!  Thanks for pointing out what you did.  And once again, thanks to each of you for your input.  It's greatly appreciated! 

Lori, CPC


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