Ob-Gyn Coding Alert

Tip: Pay attention to the modifier indicator for each of these edits.

Effective April 1, you’ve got a handful of new ob-gyn edits to apply. We’ve broken them down into fifteen highlights — ranging from vulvectomies to biopsies — to ensure your applying the latest information. 

While some of these edits make perfect sense, others have to do more with what is considered standard or expected surgical technique or surgical processes that ensure the surgery did not result in any complications – for instance bundling a cystoscopy into a paravaginal defect repair. Keeping abreast of these concepts in bundling edits will go a long way to less distress from denied claims, says Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M. 

Edit #1: CMS has bundled all of the vulvectomy codes based on their being mutually exclusive of one another. In other words, you should only be reporting one code for a vulvectomy surgery from the code range 56630-56640. The indicator is “0” for these bundles, which means you cannot use a modifier to separate these pairs.

Edit #2: Code 52000 (Cystourethroscopy [separate procedure]), is now bundled into the all codes for a paravaginal defect repair (57284, 57285 and 57423). The indicator is “0” which means you cannot bypass the edit.

Edit #3: Code 57150 (Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease) is now bundled into 45 vaginal approach procedures, and since it has a “0” indicator, you cannot bypass the bundle.

Edit #4: Code 56810 (Perineoplasty, repair of perineum, nonobstetrical [separate procedure]) is now bundled into 19 codes. These include codes for surgery on the vulva (codes 56405-56800) and some vaginal procedures (57000, 57023, 57200, 57267, 57285, and 57308). All have a “0” indicator.

Edit #5: Code 57000 (Colpotomy; with exploration) is now bundled into 18 codes.  These include all of the codes for a vaginectomy (57106-57120), excision of vaginal septum (57130), urethral plication (57220), the colporrhaphy codes (57240-57265), enterocele repair (57268), colpopexy procedures (57282, 57283), stress incontinence procedures (57287-57289), and closure of a vesicovaginal fistula (57320, 57330). All have a “0” indicator. Remember than a colpotomy is an incision into the vaginal wall and that exploration is always a part of any procedure.

Edit #6: Code 57130 (Excision of vaginal septum) is bundled into 57120 (Colpocleisis [Le Fort type]) with a “0” indicator. Colpocleisis is a procedure where the entire vaginal canal is sutured closed so you should never be paid for removing the septum before doing this closure.

Edit #7: Code 57105 (Biopsy of vaginal mucosa; extensive, requiring suture [including cysts]) is bundled into 6 codes (57130, 57230, 57250, 57260, 57265, and 57295). The indicator is “1,” meaning you can bypass the edit if: 

• this was a different encounter, 
• the biopsy was done to determine the extent of the surgery to be performed, or 
• was in an area that did not involve the primary surgical field.

Edit #8: Code 57106 (Vaginectomy, partial removal of vaginal wall) is bundled into the colporrhaphy codes 57240, 57260 and 57265. The indicator is “1.”

Edit #9: Code 57180 (Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage [separate procedure]) is bundled into 57267 and 57423. The indicator is “0.”

Edit #10: Codes 57220 (Plastic operation on urethral sphincter, vaginal approach [e.g., Kelly urethral plication]), and 57230 (Plastic repair of urethrocele) are bundled into 57295 (Revision [including removal] of prosthetic vaginal graft; vaginal approach) with an indicator of “0.”

Edit #11: Code 51703 (Insertion of temporary indwelling bladder catheter; complicated [e.g., altered anatomy, fractured catheter/balloon) is bundled into a laparoscopic paravaginal defect repair (57423) with a “1” indicator.

Edit #12: Code 57265 (Combined anteroposterior colporrhaphy; with enterocele repair) is bundled into 57423 (Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach with a “0” indicator.  This bundle resulted from the fact that 57265 includes an anterior colporrhaphy which is included as part of the paravaginal defect repair (ie, cystocele repair).

Edit #13: Code 57268 (Repair of enterocele, vaginal approach [separate procedure]) is bundled into 57425 (Laparoscopy, surgical, colpopexy [suspension of vaginal apex]) with a “0” indicator. This bundle exists because 57268 is a “separate procedure” that is almost always bundled and CMS is now catching up to some of these missed bundles.  Also when the prolapsing vaginal apex is repaired, any enterocele sac will be automatically repaired at the same time.

Edit #14: Code 38505 (Biopsy or excision of lymph node(s); by needle, superficial [e.g., cervical, inguinal, axillary]) is bundled into vulvectomy codes 56631, 56634 and 56640.  All of these codes include a lymphadenectomy. While a modifier can be used to bypass the edit, the documentation would need to show that the lymph node biopsy was not one of the lymph node areas excised or that the biopsy was needed to determine the extent of the surgery.

Edit #15: And finally, the column 1 code 56640 (Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy) has some new bundles. Code 38562, 49010, and 56633 are now permanently bundled because exploration and pelvic sampling would automatically be part of the procedure. However, retroperitoneal lymphadenectomy codes 38564 and 38570 have an indicator of “1.”