Ob-Gyn Coding Alert

Editors Note: The following case comes from several members of our Editorial Advisory Board (see listing of Board on back page). It is the presentation of an actual case in which a review of the coders first claim was found to be both incorrect and did not maximize reimbursement. We will present both the correct and incorrect coding of this case. This should help illustrate several important points in coding complex gynecological operative reports and maximizing reimbursement for these surgeries.

The billing department at a busy ob/gyn practice receives an operative report for a 72-year-old patient who had been referred to the practice by her primary physician with problems of incontinence. After several office visits with extensive physical examination and urodynamic testing the patient was scheduled for surgery. The operative report contains the following preoperative diagnoses: intrinsic sphincter deficiency (ISD) with urinary incontinence, pelvic prolapse, complete vaginal vault prolapse, cystocele, rectocele, enterocele. Additionally, buried in the body of the operative report is the diagnosis of stress incontinence.

Also, in the operative report, the physician describes the following procedures being performed:

Sling urethropexy using patch of rectus fascia

Anterior and posterior repair

Enterocele repair

McCalls culdoplasty

Iliococcygeal vaginal vault suspension

Perineorrhaphy

Cystoscopy

Suprapubic catheter placement

Understanding the Terminology and Procedures

An understanding of the terminology and procedures is particularly important to the correct coding of this case.

1. Terminology:

The womans incontinence is related to multiple problems in her abdomen and pelvic region. Weakness in the vagina walls has allowed for protrusion or herniation through the vaginal wall of the bladder (cystocele), the intestines (enterocele) and the rectum (rectocele). The structures and organs of the pelvic region are supported and held in place (especially during increased intra-abdominal pressure such as when coughing) by a system of muscles, ligaments and fascia. The excessive tearing and trauma to these supporting structures during vaginal delivery can later lead to the prolapse, or falling of these structures referred to as vaginal vault prolapse and pelvic prolapse. The prolapse changes the anatomic support for the bladder and urethra and leads to urinary incontinence.

Traditionally, urodynamic evaluations have been used to differentiate between genuine stress incontinence and other types of incontinence. The Agency for Health Care Policy and Research of the United States Department of Health and Human Services has classified genuine stress incontinence into two subtypes. The first, anatomic stress incontinence (625.6), is attributed to loss of support of the urethrovesicle junction resulting in the descent of the proximal urethra outside the sphere of abdominal pressure transmission during rises in intra-abdominal pressure. The other, intrinsic sphincter deficiency (ISD) (599.82), is attributed to poor urethral sphincter function and is commonly associated with multiple anti-incontinence procedures, menopause, or urogenital atrophy.

2. Procedures: [...]