Ob-Gyn Coding Alert

 You must know the surgical approach to choose correctly

When you've got an op note describing multiple procedures, you may find yourself confused about what you should and shouldn't report. These five tips and examples will help you get it right every time.

1. Consider Op Site Exploration as Standard

Exploration of the operative site is a standard surgical technique, which means that you cannot separately report it.

Example 1: You should always include an exploratory laparotomy (49000, Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) in any abdominal procedure (such as 58740, Lysis of adhesions [salpingolysis, ovariolysis]). You'll never code this in addition to other procedures the ob-gyn performs through the abdominal incision - which goes for other procedures that are converted from a laparoscopic to an open abdominal incision.
 
For instance, the ob-gyn performs a laparoscopic BSO (58661, Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]), but the patient begins to bleed and the procedure must be converted to an open procedure to allow an exploration and to finish the procedure.
 
Example 2: When an ob-gyn performs a diagnostic laparoscopy or diagnostic hysteroscopy, you cannot separately report them if the ob-gyn is also doing something surgically through the scope.
 
Example 3: You'll almost always include any exam under anesthesia for any vaginal approach surgery. In order to bill this separately, your documentation must indicate through a different diagnosis code that the  procedure is separate and distinct from the exam under anesthesia for the other surgical procedure.

2. Don't Code Success Checks, Anesthesia

Any procedures an ob-gyn performs during surgery to check the success of his work are considered part of the surgical technique and therefore not separately reported.
 
Another integral part of every surgical procedure is the administration of a local anesthetic by the surgeon. A surgeon might administer a local anesthetic, for example, when he is removing lesions. You'll never report this anesthesia administration in addition to the primary procedure.
 
Example 1: The physician performs a fimbrioplasty (58760) to correct occlusion of the fallopian tubes in a patient who has been unable to conceive. After the ob-gyn removes the adhesions, he performs chromotubation (58350, Chromotubation of oviduct, including materials) to check for tubal patency. In order for you to code 58350 separately, the ob-gyn must have performed this procedure prior to starting the surgery to diagnose a blockage.
 
Example 2: The ob-gyn performs a sling procedure for stress urinary incontinence (57288, Sling operation for stress incontinence [e.g., fascia or synthetic]) and then inserts a cystoscope into the bladder (52000, Cystourethro-scopy [separate procedure]) to be sure that no sutures were placed into the bladder wall.

3. Fight Uphill for Lysis of Adhesions

Most payers won't reimburse you separately for lysis of adhesions - unless you've got good documentation.
 
Such documentation would describe the adhesions' presence, extent, and so on and how they required more time or expertise than a normal surgical procedure, says Peggy Stilley, CPC, office manager for Women's Healthcare Specialists, an Oklahoma University-based private ob-gyn practice in Tulsa. "For example, the ob-gyn might document 'dense, extensive, organ-distorting adhesions that required 1.5 hours additional time to get to the operative field,' " Stilley says.
 
"I'd be sure to include an op note, which includes how much time over and above the standard operation was required and also specifically what risks the ob-gyn encountered," says Harry Stuber, MD, FACOG, an independent gynecologist in Cookeville, Tenn.
 
You may notice that the National Correct Coding Initiative bundles lysis of adhesions into many other codes - especially when the adhesions are in the area where the ob-gyn provides the surgery. "Basically, it's assumed you're lysing adhesions in order to prepare the operative field for the actual operation," Stuber says.
 
With lysis being bundled into so many procedures, and noting that NCCI usually does not permit the use of modifier -59 (Distinct procedural service) to bypass the edit, your best bet for separate reimbursement is sending in documentation of the procedure and appending modifier -22 (Unusual procedural services) to the primary surgery code.

4. Identify the Approach Every Time

You should always know the surgical approach for any surgery, because you can't select the correct codes otherwise. "It is vitally important to know what procedure the ob-gyn performs, how he or she performs it, and why he or she is doing it," Stilley says.
 
Strategy: "Search for clarification from the op note or a discussion with the surgeon," Stuber says.
 
Example: If your ob-gyn does a hysterectomy, you'll have to choose between codes for total abdominal hysterectomy (TAH), lower abdominal vaginal hysterectomy (LAVH), or a vaginal hysterectomy. These codes each have different relative values assigned to them, Stilley says.

5. Follow the General Rule

When you get ready to code for multiple procedures, make sure you follow these guidelines, Stilley and Stuber say: