Ob-Gyn Coding Alert

Although coding for hysteroscopies when the ob-gyn performs them with other services can present any number of problems, you can avoid them by paying close attention to CPT definitions and bundling rules.

Hysteroscopy is the oldest gynecologic endoscopic procedure and one of the most frequently performed for ob-gyns, according to CMS.

Hysteroscopy has many indications" including diagnosis of recurrent abnormal bleeding repetitive spontaneous abortion uterine synechiae and infertility " says Toni Revel CPC a coding expert and nurse practitioner based in Warrington Pa. By inserting the hysteroscope a thin telescope-like lighted viewing instrument through the vagina and cervix the ob-gyn can view the uterus she explains. If he or she detects areas of bleeding the doctor can use the scope to destroy the tissue by laser beam electric current or cutting away and removing it at the same time.

Although hysteroscopies may be performed alone ob-gyns frequently do them as part of a larger service to address a patient's condition(s). Such situations often lead to coding questions that you can resolve by carefully reading CPT guidelines and code descriptors.

For example an ob-gyn performs a diagnostic hysteroscopy and laser ablation of endometrial implants through the laparoscope and a chromotubation. The physician also uses the laparoscope to remove two subserosal fibroids on the surface of the uterus and eliminates other small fibroids with the laser.

To report the laparoscopic removal of the fibroids you should use 58551 (Laparoscopy surgical; with removal of leiomyomata [single or multiple]). For eliminating the endometrial implants report 58662 (Laparoscopy surgical; with fulguration or excision of lesions of the ovary pelvic viscera or peritoneal surface by any method). You should append modifier -51 (Multiple procedures) to 58662.

You can then code for the diagnostic hysteroscopy but you may have to add modifier -59 (Distinct procedural service) to 58555 (Hysteroscopy diagnostic) if the payer bundles hysteroscopies into laparoscopies. " Code 58555 is a separate procedure and may not be paid by many third-party payers when reported with other major procedures " Revel says. Appending modifier -59 to 58555 indicates to the carrier that it is a distinct separate procedure she adds. You may bill the chromotubation with 58350*-51 (Chromotu-bation of oviduct including materials) if the chromotu-bation's purpose was to diagnose a problem of tubal patency rather than to check that the other surgical procedures had not interrupted patency e.g. checking to be sure that sutures have not closed off the oviducts. Generally carriers will reimburse the chromotubation as long as the ob-gyn did not perform it to check his or her work.

Note: CPT 2003 deletes 58551. When reporting this procedure after Jan. 1 2003 you should use 58545 (Laparoscopy surgical myomectomy excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas) and 58546 ( 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams).

In another example an ob-gyn does a diagnostic laparoscopy with chromotubation and a hysteroscopy with an attempt at cannulation. The chromotubation shows patency of the left fallopian tube. Because the doctor attempts cannulation through the hysteroscope you should report 58555. You can also code for the diagnostic laparoscopy (49320 Laparoscopy abdomen peritoneum and omentum diagnostic with or without collection of specimen[s] by brushing or washing [separate procedure]) and the chromotubation (58350) because the physician performed it for diagnostic reasons.

CPT designates both 58555 and 49320 as separate procedures. This means that the payer may want modifier -59 appended to the hysteroscopy code to bypass any bundling edits it may be using. In 2002 Medicare assigned greater relative value units (RVUs) to 49320 so you would list it first followed by 58555. You should check the RVUs for 2003 when they are released to be sure this relationship still holds.

"Keep in mind when using modifier -59 to bypass Correct Coding Initiative (CCI) edits that the definition of the modifier still has to be met " says Katie Thompson RHIA a surgical coder at Southeastern Gynecologic Oncology in Alpharetta Ga. "This means it must be a different site or a different incision different session or surgery or a separate problem. A good rule of thumb is you should have a separate diagnosis when you use -59."

When you have multiple diagnoses you should link each to the appropriate procedure says Brenda Dombkowski CPC a coding specialist at Obstetric-Gynecology & Infertility Group in Cheshire Conn. "Not all the procedures performed were for all the same diagnoses. This will support the reason for the multiple procedures and the use of modifier -59."

In addition you should thoroughly review operative reports for additional procedures Dombkowski says. "I have found diagnostic hysteroscopies performed in addition to the laparoscopic procedure " which would mean you could bill the hysteroscopy separately.

When coders review a multiple-procedure operative note they may be tempted to report each of the services the ob-gyn performs. But this may not be the best method until you review the available codes in detail.

For example a physician performs a Pap smear hysteroscopy fractional dilation and curettage (D&C) cervical biopsies operative laparoscopy laser ablation of endometriosis laser lysis of adhesions left ovarian cyst aspiration and chromotubation. With such an extensive procedure the coder may be tempted to bill separately for the hysteroscopy (58555) and the D&C (58120 Dilation and curettage diagnostic and/or therapeutic).

This would be a mistake. CPT provides a single code 58558 that describes a combination of the procedures. Therefore you should not report them separately. An auditor would likely view billing 58555 and 58120 separately as abuse and an attempt to unbundle the services to maximize revenues Revel says. This could lead to demands for repayment or stiff penalties against your practice.