Ob-Gyn Coding Alert

When a patient no longer wishes to conceive babies and requests a tubal ligation, home in on your coding option(s) by focusing on technique, transaction method, and delivery involvement.

Problem: For tubal ligation coding, you've got multiple coding options: a set of codes for procedures performed vaginally or via an open approach, a set of codes for laparoscopic procedures, and a code for Essure tubal ligations.

If your ob-gyn uses a laparoscope, you will report either 58670 (Laparoscopy, surgical; with fulguration of oviducts [with or without transection]) or 58671 (... with occlusion of oviducts by device [e.g., band, clip, or Falope ring]) if a device occludes the tube, says Dori L. VanFossen, CPC, insurance and billing coordinator at Shenandoah Women's HealthCare in Harrisonburg, Va. Codes 58670 and 58671 differ based on technique regardless of whether the ob-gyn performs the ligation on its own or a day or two following a delivery. You'll use 58670 for a diathermied tube. Remember, the term "fulguration" means that tissue was destroyed by a highfrequency electric current. The physician may elect to use an electric cautery tool or a laser to accomplish this. On the other hand, if the device occludes the tube, assign 58671.

Key word: If an ob-gyn performs a "minilaparoscopic tubal," you will look to these two codes as well -- but look at the technique to determine which code to use.

If your ob-gyn does not use a laparoscope and performs an open or vaginal procedure, you will report one of these four options:

58600 -- Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral

58605 -- Ligation or transaction of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)

+58611 -- Ligation or transaction of fallopian tube(s) when done at the time of cesarean delivery or intraabdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure)

58615 -- Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach.

Keep in mind: Sometimes, physicians refer to a tubal procedure as a "Pomeroy tubal." This technique involves tying a section of the tube, then removing it. Your ob-gyn can perform this via laparoscope (58670) or via an open procedure (58600, 58605, 58611). You will not report a device code for this technique.

Also, note payers will assume every tubal code to represent a bilateral procedure. When the ob-gyn ligates only one tube or places the device on only one tube, CPT indicates you should add modifier 52 (Reduced services) to the code.

You can report the tubal ligations following a vaginal delivery (59400, 59409, 59410). If the tubal ligation occurs immediately after the delivery (during the same operative session), use 58605 with modifier 59 (Distinct procedural service) appended, says Lisa Hale, financial counselor and billing and coding specialist for Women's Physicians of Jacksonville, PA in Fla.

Remember: You should use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician provides on the same date. In this case, modifier 59 tells the payer the tubal ligation was a distinct service from the delivery (such as 59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) even though they occurred during the same session.

Because the tubal ligation requires a separate incision and is essentially unrelated to the vaginal delivery, carriers that pay for the ligation under other circumstances will generally not take issue with reimbursement using this coding sequence.

Watch out: Some carriers may pay less for tubal ligation when reported with modifier 59. Some policies reason that the ob-gyn has already done the prep work for the patient prior to delivery and therefore, payers don't need to pay twice for the same work. In other words, they treat it just like any other multiple procedure.

If the tubal ligation occurs a day or more after the delivery (during the same hospital stay), use 58605 with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). You should receive full reimbursement for the procedure.

Cesarean delivery frequently offers the ob-gyn the chance to perform tubal ligation immediately after the delivery, sparing the patient an additional surgical session.

You'll report +58611 in this case.

Red flag: Billing for tubal ligation at the time of cesarean is almost always a problem with payers because they count the cesarean incision as the incision for the ligation. To these insurers, the ligation at the same session does not represent significant effort for the ob-gyn, Hales says.

Although the American College of Obstetricians and Gynecologists (ACOG) specifically leaves tubal ligation off the list of bundled procedures in its policy on cesarean deliveries and global ob care with cesarean, some carriers will pay little or nothing extra for the procedure.

Money saver: Tubal ligation performed at the time of cesarean delivery can prove a significant source of revenue, so practices should negotiate contract renewal to ensure payers will reimburse the procedure separately from the global package or cesarean delivery codes. Also, you should point out to the payer that +58611 is an add-on procedure that does not take a modifier, experts say. The Resource-Based Relative Value Scale (RBRVS) valued this code based solely on the intraoperative work.

Your ob-gyn can also perform an Essure procedure, which involves implants into the fallopian tubes. For this procedure, you'll use 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants).

Error averted: You'll need a modifier if the ob-gyn places the device in only one tube (for instance, if the other tube was already blocked). Add modifier 52 (Reduced services) to 58565, as this is an inherently bilateral code.