# Procedure Codling Help Please



## amylynne (Jul 23, 2012)

So -- I thought i was doing pretty well re-learning this OB/Gyn stuff..... and then she handed me this.

Per the report we did:
Da Vinci Vaginal Hysterectomy
Bilateral Salpingo-oophrectomy 
Lysis of adhesions 
Sling retropubic urethropexy
Posterior colporrhaphy

Pre-op Diagnosis:
Dysfunctional Uterine Bleeding
Fibroids
Pelvic relaxation with stress urinary incontinence
Omental adhesions

There are so very many ways I could wander astray on this one....!  Any help at all would be appreciated.  - a


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## preserene (Jul 23, 2012)

Da vinci ( robtic surgery)  is a kind of  laprascopic surgery (for coding pruposes).
We have all these kinds of Hysterctomies- Abdominal hysterectomy (TAH) 
Vaginal Hysterectomy (TVH) 
Laparoscopic Assisted Vaginal Hysterectomy (LAVH) 
Robotic Assisted Vaginal Hysterectomy (RAVH).

-So , RAVH can be coded as one like LAVH.
    Check out for the combination code for LAVH and Sling surgery.( I do not have the cpt    coding book right now)
BSO does not need a separate code, as you know, it goes with hysterctomy code.
Posterior colporraphy also corporated into vaginal hysterctomy, no separate code needed.
Lysis of adhesion, if it involves more time, and energy ( work load) from the physician,  modifier could be added.
S2900 could be reported for identification purpose.


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## amyj.howe (Jul 26, 2012)

I would code as follows (based on your info, keeping in mind that I have not seen the op report):

Depending on the weight of the uterus after removal you want to code:

58552 <250g
58554 >250g

The two above codes are specific to the LAVH, but like previously stated, are used for the RAVH. These codes include the removal of adnexal structures, however other LAVH codes do not, so be careful which you choose. Lysis of adhesion is also included within these codes, again, unless extensive lysis resulting in a large amount of additional time is preformed, don't separately code. Your physician must indicate this in his or her procedure report to provide supporting documentation upon appeal.

Next I would code the sling, NOT included in the RAVH per CCI edits and procedure explanation. Not only is this a separate location and organ system, it's addressing a separate pt ailment all together.

Without viewing a procedure report, going based on what you've included, so please double check, I would use:

51992 with a 51 or 59 modifier. I would think a 59 should apply and makes the claim line more "payable" however your physician's op report and style of dictation will determine whether or not that should be used. 

Next I would code the posterior colporrhaphy, also it's own separate procedure, not inclusive to any listed above per CCI edits:

57250 with a mod 51 or 59 with the same principles as 51992.

I would list these in this order on your claim as it goes from highest to lowest RVUs making the most costly procedure the primary.

Of course you also want to remember to apply your ICD-9s to the appropriate line items, this will effect claim processing and payment. Hope this helps!


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## preserene (Jul 26, 2012)

Posterior colporraphy is in integral part of ( included step of ) vaginal hysterectomy. ( the surgery here is a Da vinci *vaginal hysterctomy which includes vaginal approach*.
It was not an open(alone) vaginal hysterectomy it was Da Vince ( endoscopic/laparpscopic asstd).
We have  Comb. codes for Vaginal Hysterectomy with sling operation- with uterus , 250grms or less, with colpo-urethrocystopexy Marshall Marchetti-Kranz type , Pereyra type , with or without ENDOSCOPIC CONTROL- 58267 
OR
 for 250 gram or more uterus vaginal hysterectomy WITH colpourethrocystopexy Marshal Mar... type, Pereyra type, WITH or without ENDOSCOPIC CONTROL - 58293.
 Either of these code surgery incorporates posterior colporraphy.*So no need for coding colporrphaphy separately*. It is a part and parcel of the vaginal hysterectomy surgery.

 Colporraphy, BSO all gets bundled into the major prodecure.

So to consolidate the report could be:
58267 or 58293, ( which is the most major procedure), depending on the size of the uterus rspectively, with a modifier -22 for lysis of adhesion.

This my view. Let us ponder whether this makes a good code sense.
I do not know if there is a definite edit for this particular combination of surgery. 
Of course it is a very major & complex surgery involving many hours.
When we have a code for this combined surgical procedure as I mentioned why not give it?  This for the GYN physician claim code. 
If a surgeon or Urologist combined /joined the surgery, you know, the claim for them would be separate.I am not coming to that.
Hope I make some sense.. 
So we can not be sure as you said, we are provided with the true surgical procedure picture.
Thank you very much


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## amyj.howe (Jul 26, 2012)

I understood that it was not an open procedure. I indicated an LAVH with salpingo-oopherectomy as per the description of codes 58267 and 58293 I didn't see indication of additional value being allowed for the removal of those structures. With the codes I suggested, the colporrhaphy and sling are not included. Additionally 58267 and 58293 don't indicate the use of a sling as mentioned in the original post, it indicates the Marshal-Marchetti-Krantz type or Pereyra type which utilize sutures to suspend or elevate the bladder. The code I suggested 58992, specifically indicates a lap sling operation for stress incontinence (not open, which would be 57288). 

I would disagree that a posterior colporrhaphy is an integral part of a RAVH (58552) simply because I have seen hundreds of case in which a colporrhaphy was never completed during the course of a LA or RAVH because it was not needed. Bear in mind that I chose the secondary and tertiary codes based on my primary, not yours. It may be integral to the CPTs you listed, I have not checked. Based on the DX (pelvic relaxation with urinary stress incontinence) listed it indicates to me that the colporrhaphy was related to the repair of a rectocele, which is why I chose 57250. I also chose this code as the listed procedure indicates a posterior colporrhaphy, which is exactly what 57250 is. This has no relation to the laparoscopic procedure what so ever as it's an entirely different approach.

I maintain, based on your observation, my choices. Does this make good code sense? To assume that a very detailed, integrated and time consuming procedure is "bundled" in one code that only indicates 1 1/2 (as 58267 and 58293 offer a different technique for the sling retropubic urethropexy) of the 5 separately listed codes? Or to select more descriptive codes, that are not inclusive to each other, which in total will account for all services rendered and obtain appropriate payment with proper modifications? 

In reference to utilization of combined surgical codes, they are appropriate when the procedures combined in that code are the ones completed. Additionally 58552 and 58554 are codes that indicate multiple procedures, just not the same two in 58267 and 58293.

Amy Lynne~I would look up all the codes provided 58267, 58293, 58552, 58554, 51992 and 57250 and use them as a point of reference in reviewing your op report. Often times I find what has been dictated isn't what is actually listed at the beginning of my reports under procedures. Either one of us could be right, or we could both be wrong. I'd also like to suggest looking into an OB/GYN specific coding companion if you're just getting back into the swing of things, it can be very useful. Good luck!


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## amylynne (Jul 27, 2012)

*Thank You Ladies*

Wow.... well, I have to tell you, I was kind of relieved to see this much discussion on this one.  When I started digging into this I found myself walking the exact lines that the two of you pointed out!  It's nice to know that I was at least in the vicinity of the correct codes on this one.  

Amy - I have the OB/GYN coding compantion from Optum -- Is there and additional one you would recommend?  

- a


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## amyj.howe (Jul 27, 2012)

I like the Ingenix OB/GYN coding companion but I've not ever used the Optum, they could be similar. All of my code books have always been Ingenix therefore I'm used to their layout and that helps with my ease of use. 

So you can compare, the book I use is has the code look up index in the back and each page, per code, of the book give an illustration, detailed break down of the procedure, coding tips, icd-9 procedural codes (which don't really pertain to professional billing), anesthesia codes, ICD-9 Diagnostics codes that commonly apply, medical terms that pertain to the procedure are defined, CCI edits, Medicare Edits and Facility and Non-Facility RVUs. So basically anything and everything you could wonder about a specific OB/GYN code.

And, of course, Google is always a great tool!! =D


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## memory1963 (Aug 23, 2012)

Can any of you help me with the >250  grams and < 250???? my boss is concerned about whether the patholgist is just weighing the uterus and there is nothing else attached. 
and wanted me to google it and I can find NOTHING related to that. Do you go by the weight the path report says???? when i read the report it seems clear to me but she is concerned since the uterus weighed 350 grams. Any help would be appreciated.
Thanks


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## amyj.howe (Aug 24, 2012)

I code based on the path report as this is the documentation you'd submit if an appeal were necessary. If the uterus weighed 350, how is the pathologist coming up with a different weight? My reports normally indicate a total weight of uterus and any leiomyomas etc....


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