Ob-Gyn Coding Alert

Editors note: This month, Ob-Gyn Coding Alert adds a new feature to its lineup. In this feature, we will highlight a challenging coding case submitted by a subscriber. The case will be described in detail, based on information provided. Then, ob/gyn coding experts will dissect and analyze the case, defining the relevant medical terminology and coding issues, and offering useful tips to help your practice receive all of the reimbursement to which it is entitled. This months case comes from Deb Ezinga, of Advantage Health Obstetrics and Gynecology of Grand Rapids, MI.

After a two-year absence, a 77-year-old woman visits her gynecologist complaining of a frequent urge to pass urine and the involuntary passing of urine during coughing. She also suffers from of a bulging of the perineum. After a thorough examination and several tests, the gynecologist determines that the patient has several problemsanatomic incontinence, vaginal prolapse, and an enterocele. There is discussion about inserting a pessary (to deal with the prolapse), but instead, the woman decides to have surgery. Surgery is scheduled and performed successfully. The operative report records that the following procedures were done:

1. Sacral colpopexy

2. Burch anterior urethropexy

3. Moschowitz enterocele repair

4. Paravaginal urethropexy

The question is: How can you code these surgical procedures for optimal Medicare reimbursement?

Understanding the Terminology and Procedures

A. Terminology. Correct coding begins by ascertaining a clear understanding of the diagnoses entered into the chart by the provider and the procedures performed. In this case:

1. Incontinence (subdivided into stress and urge incontinence) is the involuntary passing of urine, most often caused by age and the long-term effects of childbearing. More specifically, this patient probably experienced a loss of urethral support and downward displacement of the urethra; these anatomical changes led to the incontinence during periods that the body was under stress, such as coughing.

2. Vaginal prolapse refers to the loss of support and downward drop of the vaginal walls.

3. The weakness in the vaginal walls has allowed an enterocele to form, which describes the herniation of the intestine through the vaginal wall.

B. Procedures. The colpopexy is an abdominal procedure used to repair the prolapsed vagina. It may be suspended by fixation to the abdominal wall (57282), by attachment to the sacrum (57280), by strips (57288), or by the use of the round ligaments (58400). The Moschowitz enterocele repair (57270) is an abdominal procedure that uses a series of sutures to tighten the vaginal walls and prohibit the herniation. The anatomical incontinence is repaired with the Burch anterior urethropexy (51840) and the paravaginal urethropexy (57284). Both of these procedures use sutures to support the structures that have allowed for the displacement of the urethra.

Optimize Coding With the Pre-operative Notes and Post-Operative Report

Here are the strategies to use for optimal coding of this operation. Although outlined here dealing with a specific case, these methods may prove useful in other situations.

1. Often the operative report will provide an itemized list of everything that was done, but will not provide enough information for correct or optimal coding. In this case, the practice coder needs more information, including the pre- and post-operative reports and the most recent Medicare policy, detailing which procedures are bundled.

2. The diagnosis codes for this case emerge from the pre-operative notes and the post-operative report. With the information provided here, the prime diagnosis code would be 618.6 for genital prolapse that also includes the enterocele. In addition, the coder should report ICD-9 code 788.33 for mixed incontinence because the patient experienced both urge and stress symptoms.

3. The procedures should be coded with the following considerations in mind: According to the most recent edits to the Correct Coding Initiative, the software program Medicare carriers use to determine correct coding policy, the Burch anterior urethropexy (51840) is included in the paravaginal urethropexy (57284). Therefore, you will use 57284 for both. Also, the Moschcowitz enterocele repair (57270) is included in the sacral colpopexy (57280) so you will only bill the 57280.

4. Determine which of the two billable procedures, 57248 and 57280, has the most relative value units (RVUs). 57280 has a higher relative value than 57284, so it should be listed first. The code 57280 will be listed second along with the 51 modifier (multiple procedures) as it is a multiple procedure.

Note: If you have a case you would like to see covered as the Case of the Month, please fax a brief description to OCA at 800-508-2592.

Medical Terminology Related to Colpopexy/Urethropexy Enterocele hernia of intestine through the vagina. Colpopexy suture of a relaxed and prolapsed vagina to the abdominal wall. Urethropexy surgical fixation of the urethra. Vaginal prolapse - a relaxation, falling or dropping downward of the vaginal wall.

Article contributors: Expert advice in 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; Thomas Kent, CMM, principal, Kent Medical Management, MD; Dunihoo DR. Fundamentals of Gynecology and Obstetrics. J.B. Lippincott and Co.; Philadelphia: 1990; Coding for Obstetrics and Gynecology. MMI, Alpharetta, GA; 1997.