| Latest on CPT Code 57160 for Pessary Coding from Codify's Ob-Gyn Coding Alert. 3 Tips Power Up Your Pessary Coding Find out if the ob-gyn did a refitting at the time of an insertion. If you think 57160 is all you need for pessary insertion procedures, think again. Not only will you have to consult the HCPCS and ICD-9 manuals, you must follow your practice's policy on whether the patient or you are responsible for the supplies. What it is: A pessary is a support device for pelvic-floor weakness, such as uterine prolapse, vaginal prolapse (enterocele, cystocele, rectocele), and stress urinary incontinence. The pessary device is the most common - and occasionally the only - nonsurgical option for treating advanced uterine prolapse. Tip 1: Use 57160 for New... ...to read the full article and to get access to our ob-gyn newsletter archives, subscribe to Codify's Ob-gyn Coding Alert (a monthly newsletter that covers all the latest information to help you code accurately).
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A limited number of supply and insertion codes, plus the need to bill different payers for different aspects of pessary service, make pessary supply, insertion, cleaning and reinsertion for Medicare patients one of the most vexing
coding problems for ob/gyns. Knowing the pitfalls and solutions to pessary supply and related services will ease the reimbursement struggle.
A pessary is a ring-shaped device worn in the vagina to support a displaced or prolapsed vagina or uterus. This prolapse is caused by the weakening of muscles and ligaments that hold the uterus in place due to multiple vaginal deliveries obesity hormonal changes or old age hence the large number of Medicare patients treated for the condition. A pessary is the most common (and in some cases the only) nonsurgical option for relieving advanced uterine prolapse. They must be removed and cleaned about once a month.
Because pessaries are considered both a supply and an orthotic by Medicare they have HCPCS codes: A4561 is for a rubber pessary and A4562 is for any non-rubber pessary. These codes are new as of 2001 and replace deleted code A4560.
Code A4562 is likely to be more frequently used as it is for a silicone pessary. Women fitted with silicone rather than rubber pessaries tend to have fewer allergic reactions to the material. Also reimbursement for A4561 is still much lower than that for A4562 says
Carla Bryan CPC office manager of WomenCare a two-physician one-nurse midwife practice in Hartsville S.C. Our physicians prefer to prescribe the rubber pessary and we only get reimbursed about $20 from the DMERC (durable medical equipment regional carrier) when the actual cost of the supply is about twice that.
Reimbursement rates for A4562 are closer to the cost of the device. As of January 2001 A4562 pays between $44.25 and $53.11 depending on the state. Prior to this pessary reimburse-ment was as low as $12 per item.
There is one CPT code for pessary insertion: 57160* (
fitting and insertion of pessary or other intravaginal support device). The asterisk after the code indicates that this service includes the surgical procedure only and both CPT and Medicare have assigned the code zero global days. If the patient reports for her yearly exam and at the same time has the pessary fitted and inserted 57160* would still be used. If this is also the year the patient is eligible for her screening pelvic and breast exam under Medicare guidelines you would also bill for the pessary insertion and the screening exam using HCPCS code G0101 (
cervical or vaginal cancer screening; pelvic and clinical breast examination). For cleaning and reinsertion of the pessary the appropriate evaluation and management (E/M) code for an established patient (99211-99215) is applied depending on the exam and medical decision-making documented in the chart at the time of the encounter.
The corresponding ICD-9 codes for genital prolapse include 618.0 (
vaginal prolapse without mention of uterine prolapse) and 618.1 (
uterine prolapse without mention of vaginal wall prolapse). Other codes within the 618.x family apply based on the degree of prolapse or in the case of combined uterovaginal prolapse.
Billing the DMERC The main reimbursement challenge for pessary coding lies with the DMERC a Medicare intermediary carrier that accepts billing for pessaries as well as other DME such as nebulizers wheelchairs and certain orthopedic devices. In 1992 HCFA divided the country into four DMERC areas (see box on page 19). Private health insurance companies contract with HCFA to be the DME regional carrier for a given area of the country. Depending on where the patient lives not where care was administered the coder sends the bills for A4561 and A4562 to the appropriate DMERC and bills the local Part B carrier for 57160* plus any subsequent E/M service for cleaning and reinsertion. The only accepted entry on the claim for the pessary supply place of service is home (the location where the patient uses the pessary).
To bill a DMERC for the pessary supply codes the physician or group practice must have a supplier number obtained from the National Supplier Clearinghouse (see box below for contact information). The
ob/gyn orders the pessary from a private medical supplier and submits the bill to the DMERC. If you dont have a supplier number you cannot bill the DMERC for the pessary supply says
Melanie Witt RN CPC MA ob/gyn coding expert and an independent coding educator based in Fredericksburg Va. Likewise you cannot obtain the pessary from a supplier sell it to the patient and then have the patient try to obtain reimbursement from the DMERC on her own.
Witt explains that for Part B providers the alternative to working with the DMERC is to write a prescription for the pessary and have the patient take it to a local pharmacy or medical supply company and fill it. The patient returns to the ob/gyns office to have the device inserted and the ob/gyn bills Medicare for 57160* only. It is then up to the patient to submit a claim to the DMERC for the pessary. However in DMERC Region D patients may not submit claims directly to the DMERC per that carriers rules.
For practices that treat many Medicare patients it may be worthwhile to obtain the supplier number if one is not already on hand. Practices have complained of cumbersome paperwork and a lengthy filing process before a supplier number is obtained. The good news is that HCFA recently introduced form 855S " a simpler version of the supplier number request form. The form is available for download at the National Supplier Clearinghouse:
www.pgba.com/palmetto/main.nsf/allframesets/pro_nati.html.DMERC Regions
To contact the National Supplier Clearinghouse:
PO Box 100142
Columbia" SC " 29202-3142
Phone: 866-238-9652
The DMERC areas of jurisdiction are as follows:
Region A: Connecticut" Delaware Maine Massachusetts New Hampshire New Jersey New York Pennsylvania " Rhode Island and Vermont. Claims should be directed to:
HealthNow NY" " Inc.
PO Box 6800
Wilkes-Barre" " PA 18773-6800
Region B: District of Columbia" Illinois Indiana Maryland Michigan Minnesota Ohio Virginia " West Virginia and Wisconsin. Claims should be directed to:
AdminiStar Federal" " Inc.
8115 Knue Road
Indianapolis" " IN 46250
Region C: Alabama" Arkansas Colorado Florida Georgia Kentucky Louisiana Mississippi New Mexico North Carolina Oklahoma Puerto Rico South Carolina Tennessee " Texas and Virgin Islands. Claims should be directed to:
Palmetto GBA
PO Box 100141" " Suite 500
Columbia" " SC 29202-3141
Region D: Alaska" American Samoa Arizona California Guam Hawaii Idaho Iowa Kansas Mariana Islands Missouri Montana Nebraska Nevada North Dakota Oregon South Dakota Utah " Washington and Wyoming. Claims should be directed to:
CIGNA
PO Box 690
Nashville" TN 37202 |
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