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 [...]