Ob-Gyn Coding Alert

As of Jan. 1, you should be using new CPT 2008 ob-gyn codes -- but learning what they are and when you should report them isn't often the end of the story.

The Correct Coding Initiative (CCI), version 14.0, applies a slew of bundles to your daily coding practice and limits what services you can report in conjunction, thanks to two new codes for paravaginal repairs and four new codes for laparoscopic hysterectomies.

For many years, you-ve had to take into account that a sling procedure (57288, Sling operation for stress incontinence [e.g., fascia or synthetic]) is a component of the only existing code for a paravaginal defect repair: 57284 (Paravaginal defect repair [including repair of cystocele, stress urinary incontinence, and/or incomplete vaginal prolapse]).

However, CPT 2008 revised 57284 to make this an open procedure that includes only a cystocele repair: Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach.

CPT 2008 also added two new codes to represent the vaginal (57285, - vaginal approach) and laparoscopic approaches (57423, Paravaginal defect repair [including repair of cystocele, if performed], laparoscopic approach). Therefore, "CCI made some changes to the existing bundles for code 57284, which brings about both good and bad news," says Melanie Witt, RN, CPC-OGS, MA, a coding expert based out of Guadalupita, N.M.

Bad news: Like before, you-ll still have to count a sling procedure (57288) as a component to 57284. Also, CCI 14.0 now includes 57284 in these services:

Don't miss: You should take into account that 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence) and 57260 (Combined anteroposterior colporrhaphy) are now components of 57284.

Good news: The good news is you can report the sling procedure (57288) with the new paravaginal repair codes (57285 or 57423). "The American College of Obstetricians and Gynecologists (ACOG) is working to have the sling bundle with code 57284 remedied for CCI 14.1," Witt says.

In a nutshell: For this reason, you must know the approach of the paravaginal repair before assigning the code, says Lana Flatt, CPC, office manager of OB/GYN Associates in Cookeville, Tenn. You will be able to report the sling procedure (57288) if the ob-gyn performed a vaginal approach or laparoscopic paravaginal defect repair.

The new codes you had to learn for CPT 2008 included parenthetical notes instructing you not to bill the new service with a variety of other codes -- and CCI 14.0 agrees.

For instance, you should not bill a vaginal paravaginal repair (57285) in conjunction with 51990, 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), 57260, 57265 (Combined anteroposterior colporrhaphy; with enterocele repair) or +57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [list separately in addition to code for primary procedure]).

The same goes for laparoscopic paravaginal repair (57423) in conjunction with 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple), 51841 (- complicated [e.g., secondary repair]), 51990, 57240, 57260, 58152 or 58267.

While all but the TAH/BSO with MMK or Burch procedure bundle 58152, you can override these edits using a modifier, such as modifier 59, Distinct procedural service. Watch out: This should be a modifier of last resort. You have to meet the criteria, and that would be hard to document.

Bottom line: "You have to have documentation to justify breaking the CCI bundle. Sometimes, even with documentation, the edit can't be broken," Flatt says.

Example: If the physician had performed both an anterior repair and a posterior repair with the vaginal paravaginal repair, you would be more correct to report the posterior repair with 57250 than 57265. Why? Because the anterior repair is in the same location as the paravaginal repair and would not qualify as a separate procedure you can bill in addition. If the ob-gyn adds the mesh at the time of a posterior repair, you would need to add modifier 59 to 57267, but any mesh your ob-gyn uses as part of the anterior repair you should consider included in the paravaginal repair, Witt says.

Along the same lines as the above edits, CPT 2008 indicates that you should not report the new total laparoscopic hysterectomy codes (58570-58573) with 49320, 57000, 57180, 58140-58146, 58150, 58545-58546, 58561, 58661 or 58670-58671. CCI 14.0 confirms this advice but also bundles this type of hysterectomy with all myomectomy, other hysterectomy, BSO or oophorectomy codes as well. In addition, version 14.0 also bundles all of the major lysis codes, including those for enterolysis, salpingolysis and ureterolysis.

Highlight: "What is interesting is that only lysis of bowel adhesion (44005) never allows for a modifier to bypass the edit," Witt says. When your ob-gyn performs other types of adhesiolysis, CCI allows you to use modifier 59 when the criteria for doing so are met. "This would mean that the adhesions would have to be located in a site other than those involving the uterus and/or the ovaries (if the physician is removing them)," Witt says. The lysis of bowel adhesion (44005) forbids you from taking this into account.

You-ll also find some bundling additions to existing codes in these separate patterns.

First, chromotubation (58350) is now part of most of the tubal procedures, such as ligations, lysis, and tubal repair. "You can use modifier 59 under some circumstances, but be sure not to bill for chromotubation that the ob-gyn does to check his work," Witt says.

The second series of additions comes with the renumbering of the codes for an abdominal approach cyst/endometrioma removal (49200-49201) to new codes 49203-49205. Expect to see the new code numbers replacing the old for all current bundles. They-ve also been added to 58943 (Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy[s], with or without omentectomy).

Watch out: "The conversion to the new codes is not consistent for all the primary codes in which they were bundled last year," Witt says. For instance, CCI 14.0 did not add the new codes as bundles to 58150, 58180, or 58950, even though CCI 13.2 bundled the old codes with these procedures.

And finally, you can count myomectomy codes as being components of laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopic supracervical hysterectomy procedures.

Want to learn more? To download a free copy of CCI Version 14.0 go to http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.