Ob-Gyn Coding Alert

Editors Note: A goal of all coding should be to accurately report the services provided to the patient with precise justification. However, in some cases, more than one correct coding option is possible. This case considers two options and explains why one may provide greater reimbursement than the other. This case also considers the question of medical necessity for what may appear to be an optional hysterectomy. If you have a case youd like to submit for consideration, please send it via fax, email or mail.

The patient is a 50-year-old nulligravida female who has been treated medically for stress urinary incontinence for almost a year, with little success. She is considering having the urinary incontinence treated surgically, but before she has decided, she presents in the office with right abdominal cramping. She states that both her mother and her mothers sister developed ovarian cancers in their early 60s and she is quite worried that her pain may be related to that problem. The patient was on oral contraceptives for six years during her life. Pelvic exam at this visit reveals a right ovarian mass. An ultrasound is performed in the office, which shows a 3 cm right ovarian cyst that is possibly endometrial in nature. After extensive counseling regarding management of the cyst, the likelihood of her developing ovarian cancer and the failure of medical treatment to satisfactorily alleviate her stress urinary incontinence, she elects to proceed with hysterectomy and BSO and a pereyra urethropexy.

At the time of surgery (two weeks later), the physician confirms a chocolate cyst of the right ovary. Inspection of the posterior cul-de-sac reveals a moderate enterocele that is repaired using high plication of the uterosacral ligaments and a McCall plication of the enterocele itself.

Terminology and Procedures

This patient is found to have several problems that justify her surgery. First, her abdominal pain is being caused by an ovarian cyst that is more correctly identified as ovarian endometriosis, ICD-9 code 617.1. Endometriosis occurs when a small portion of the tissue lining the uterus (the endometrium) begins to grow in another part of the body. Up to 10 percent of women experience some form of endometriosis. In most cases, this growth develops in the pelvic area, on the ovaries, the lining of the pelvic cavity, ligaments or the fallopian tubes. As these growths are made of endometrial tissue, they usually behave like the endometrium, responding to the hormones of the menstrual cycle. Each month, they build up tissue and slough it off. As a result, pain, internal bleeding, inflammation, cysts and scar tissue can develop in the affected areas.

In this womans case, the endometrial tissue has grown in the ovary and old dark brown blood has collected over time from repeated hemorrhage in the cystic space in the ovary and produced a so-called chocolate cyst. The cyst coupled with the womans family history of ovarian cancer (V16.41) puts her at a high risk for developing ovarian cancer.

Secondly, this womans stress urinary incontinence 625.6 is a result of a weakening in the vaginal wall that has allowed for a herniation of the intestine (enterocele). This herniation affects the urethra and results in incontinence during times of stress.

To manage the ovarian cyst and the risk of cancer, the procedures performed include a vaginal hysterectomy (removal of uterus) and a bilateral salpingo-oophorectomy (removal of tubes and ovaries). To manage the stress urinary incontinence and repair the enterocele, the procedure is a plication (stitching or pinning) of the fallen or weakened areas of the vaginal wall with a procedure called a pereyra urethropexy.

Coders Notebook

There are two possible ways to code for this case.

Option 1: The removal of uterus, tubes, ovaries, and enterocele repair can all be coded using code 58263 (vaginal hysterectomy), and the pereyra can be coded with the code 57289 (pereyra procedure) with the -51 modifier added to indicate this is a multiple procedure.

Option 2: The vaginal hysterectomy can be coded with the Pereyra using code 58267 (vaginal hysterectomy with colpo-urethrocystopexy, the removal of tubes and ovaries) with code 58720 (salpingo-oophorectomy), and the enterocele repair with code 57268 (repair of enterocele). The 58720 and the 57268 must both be appended with modifier -59 and -51.

If you consider the RVUs for each of the procedures being billed, it would appear that Option 2 might bring the higher reimbursement, but it also involves coding for CPT separate procedures, which often lead to denials because the payer, despite the use of a modifier -59, may decide that these procedures are bundled into the vaginal hysterectomy. Also, the code 58720 does not clearly identify whether the salpingo-oophorectomy is considered to be an abdominal or vaginal approach. During this surgery, it should be apparent that the tubes and ovaries were removed vaginally.

The V code for family history of ovarian cancer is important to use in this case because the patient has elected to have a hysterectomy with BSO and the other diagnoses do not alone justify this procedure. Remember, however, that some payers may decide that elective surgery for a condition not currently in evidence (removal of the ovaries because of familial ovarian syndrome) is not a covered benefit under the patients policy. This physician would be wise to preauthorize the procedures and communicate to the patient any portion of the surgery that will be her financial responsibility if coverage is an issue.

Article contributors: Expert advice for this case study was provided by the following sources: Melanie Witt, RN, CPC, MA, program manager, department of coding and nomenclature, American College of Obstetricians and Gynecologists, Washington, DC; Evelyn M. Gross, CMM, CPC, NR-CMA, healthcare specialist, E.M. Gross and Associates, South Amboy, NJ; Thomas Kent, CMM, principal, Kent Medical Management, Dunkirk, MD; Dunnihoo, DR, Fundamentals of Gynecology and Obstetrics, J.B. Lippincott and Co.: Philadelphia 1990.