EM Coding Alert

Hint: You may be able to report multiple E/M services in some situations.

Coding pessary insertion means navigating various procedure codes — and some services are included in the E/M code. In fact, although there’s only one CPT^® code for pessary insertion, you may not need to report 57160 at all.

Grab your HCPCS and ICD-10-CM manuals and read this expert advice, so you can approach pessary insertion encounters with the knowledge you need.

Tip 1: Define Pessary

A pessary is a support device for pelvic-floor weakness, such as uterine prolapse, vaginal prolapse (enterocele, cystocele, rectocele), and stress urinary incontinence, experts say. The pessary device is the most common — and occasionally the only — nonsurgical option for treating advanced uterine prolapse.

Causes: Weakening of the muscles and ligaments that hold the uterus in place, which could be triggered by multiple vaginal deliveries, obesity, hormonal changes, or old age, can cause the prolapse. Your most common ICD-10-CM codes to link to pessary devices are N81.2 (Incomplete uterovaginal prolapse), N81.3 (Complete uterovaginal prolapse), N81.4 (Uterovaginal prolapse, unspecified), and N81.8 (Other female genital prolapse), says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, New Mexico.

Tip 2: Rely on E/M Code for Reinsertion

CPT^® provides you with only one code for pessary insertion: 57160 (Fitting and insertion of pessary or other intravaginal support device). This code has no global days.

Suppose the patient presents with prolapse symptoms, and the ob-gyn makes the decision to insert the pessary during the same visit. You should report 57160 in addition to the exam code (such as 99211-99215, Office or other outpatient visit …). Remember to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service.

Watch out: However, Medicare includes the decision to do minor surgery with the performance of that procedure and states it is not appropriate to bill a separate E/M if this is the case. While Medicare may not know this at the time you submit the claim, it will note the global days assigned to 57160, which may lead to a review after the fact, Witt says.

On the other hand, suppose a Medicare patient is eligible for her screening pelvic and breast exam, and during this visit the ob-gyn inserts a pessary. You should report the pessary insertion with 57160 in addition to G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). Note that you do not add modifier 25 to G0101 because it is not an E/M service.

Red flag: If the patient returns for the cleaning and reinsertion of the pessary, you should report the E/M code for an established patient (99211-99215), depending on the examination and medical decision making (MDM) your ob-gyn documents in the chart. You would not include 57160. The E/M service includes the cleaning and reinsertion. The only way you could report 57160 again would be if the ob-gyn inserted a new pessary. Sometimes the ob-gyn may feel that they did a refitting at the time of the reinsertion and may feel justified to report 57160 again. Rule: Unless the ob-gyn refits a new pessary, you can only bill an E/M service, never 57160.

Best bet: Find out if your ob-gyn is doing an initial fitting and insertion or a cleaning and reinsertion without a fitting, Witt says. Show the CPT^® description of 57160 to your ob-gyn to help make the decision.

Tip 3: Navigate Device Category With Care

Medicare considers pessaries both a supply and prosthetic device. You should report them using the following HCPCS codes:

• A4561 (Pessary, rubber, any type)
• A4562 (Pessary, non rubber, any type)

You’re likely to use A4562 more than A4561. The reason is that A4562 represents silicone pessaries. Women fitted with silicone pessaries, rather than rubber ones, tend to have fewer allergic reactions to the material.

Strategy 1: The problem with your practice providing the pessaries to patients is that the reimbursement for these devices may be less than the manufacturers’ price. For instance, in 2023, you can expect payment from $60 to $80 for a silicone pessary under the Medicare payment schedule depending on your location. What you can do is have your ob-gyn provide the patient with a prescription to purchase the pessary directly from the supplier and then bring it to the office for the insertion (57160), Witt says.

Strategy 2: If your practice does provide the pessary to the patient, you should bill the insurance or Medicare for the device along with the pessary insertion (57160).

Keep in mind: You would bill the pessary to the Part B carrier because Medicare considers pessaries supplies.