Ob-Gyn Coding Alert

Correct Coding Initiative (CCI) version 8.3 makes an across-the-board change, bundling 11 injection codes into every comprehensive surgical code that did not already have them listed. The new code edits are effective Oct. 1.

There are 1,916 new code bundles for gynecology codes and 616 new bundles for obstetric codes in CCI 8.3. Despite these numbers, there were no dramatic changes that should concern ob-gyn coders in general. A few mutually exclusive code bundles have been added, but none were deleted for codes that ob-gyn coders use. In addition, none of the changes to the "0" and "1" bypass indicators from the previous CCI version affected ob-gyn billing.

CCI 8.3 bundles 11 injection codes into every comprehensive surgical code:

36000* Introduction of needle or intracatheter, vein

36410* Venipuncture, child over age 3 years or adult, necessitating physicians skill (separate procedure), for diagnostic or therapeutic purposes. Not to be used for routine venipuncture

37202 Transcatheter therapy, infusion other than for thrombolysis, any type (e.g., spasmolytic, vasoconstrictive)

62318 Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

62319 lumbar, sacral (caudal)

64415* Injection, anesthetic agent; brachial plexus

64417* axillary nerve

64450* other peripheral nerve or branch

64470 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level

64475 lumbar or sacral, single level

90780 Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour.

CCI bundled 36000, 36410 and 90780 because they are considered a standard of practice. The rest of the codes were added because they represent possible anesthesia services that would be included in the surgical procedure, if performed. Of course, all of these codes can be reported separately with the appropriate modifier if the physician believes that the service is distinct from or unrelated to the primary procedure.

Version 8.3 includes additional edits that affect codes frequently reported by ob-gyn practices. For example, a limited pelvic and para-aortic staging lymphadenectomy (38562) has been bundled with the codes for resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy (BSO), omentectomy and radical debulking (58952) and a BSO with omentectomy, total abdominal hysterectomy (TAH) and radical debulking (58953). You cannot bypass this bundle by using a modifier.

"These changes will not greatly affect our ob-gyn physicians," says Socorro Ramon, coding educator for Ob Gyn Associates in Houston. Oncology physicians usually perform the lymphadenectomy portion of the surgery, while the practices ob-gyn surgeons do the gynecological portion, she says.

Similarly, CCI 8.3 bundles a pelvic lymphadenectomy (38770) with codes 58952, 58953 and 58954 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy). Medicare never pays for these code combinations under any circumstances.

Version 8.3 also bundles a retroperitoneal transab-dominal lymphadenectomy (38780) with 58952, 58953 and 58954. You can bypass this coding edit by using a modifier.

The new CCI groups peritoneocentesis, abdominal paracentesis or peritoneal lavage (49080) with the codes for resection of ovarian, tubal or primary peritoneal malignancy (58950-58952) and codes 58953-58954. If the ob-gyn performs the lavage or peritoneocentesis as a distinct or unrelated procedure at the time of the surgery for the malignancy, you can report both procedures with the appropriate modifier to bypass the edit.

The new edits also bundle cystourethroscopy with irrigation and evacuation of clots (52001) with the two anterior vesicourethropexy codes (51840 and 51841) and the code for an abdomino-vaginal vesical neck suspension (51845). CCI has also grouped this cysto procedure with G0002 (Office procedure, insertion of temporary indwelling catheter, Foley type [separate procedure]). You can report this bundled code with the appropriate modifier if the physician performs the procedure as an unrelated or distinct procedure.

"We have urogynecologists who perform uro procedures and our ob-gyn physicians assist," Ramon says. "We bill all these services using modifiers -51 (Multiple procedures), -59 (Distinct procedural service) and -80 (Assistant surgeon). So the 52001 bundled with 51840, 51841 and 51845 may be something to track for reimbursement."

Medicare has also added some code bundles to E/M services. CPT rules state that the highest level of the most extensive E/M service provided on the same day should be the one reported. The new edits coincide with that rule. "These edits will have little affect on the ob-gyn coding that I do for my office," says Lana Flatt, a veteran coder for Ob Gyn Associates in Cookeville, Tenn. "We normally would bill only one E/M service per day, whether office, hospital, observation, etc."

CCI 8.3 bundles all of the office outpatient codes (99201-99215) into the observation care codes (99218-99220 and 99234-99236). Although you can bypass this edit with the appropriate modifiers, be sure the documentation indicates that the E/M services are not related to one another.

In addition, the new edits bundle observation care (99218-99220) and inpatient care (99221-99233) with codes designated for observation or inpatient admission and discharge on the same day (99234-99236). Medicare will never pay these code combinations, and the CCI edit matches the CPT guidelines for reporting these services.

Version 8.3 also groups all of the outpatient consultation codes (99241-99245), confirmatory consultation codes (99271-99275), emergency department services (99281-99285), nursing facility care (99301-99313), domiciliary care (99321-99333) and home visits (99341-99350) with the codes for observation care (99218-99220) and the observation or inpatient admission and discharge codes (99234-99236). You can bypass these code bundles with the appropriate modifier, but again be sure that the documentation clearly supports two unrelated visits on the same day.

"We do not have a very large group of Medicare patients, but if the HMOs follow Medicares bundling practices, then we may have a problem," Ramon says. Her practice has a "special procedures room" where ob-gyns perform some minor procedures. If the physician sees the patient in the office prior to such a procedure, then sends her to the hospital for observation, "coding issues may arise," Ramon cautions.

The mutually exclusive bundles include grouping several codes for liver tumor ablation (47370, 47371 and 47382) with 49200 (Excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas). Also, version 8.3 bundles two of the liver tumor ablation codes (47370 and 47371) with 49201 ( extensive). You can bypass all of these code bundles with the appropriate modifier if they are distinct from the primary procedure or unrelated to it.

Similarly, the CCI update bundles the removal of a nonbiodegradable drug delivery implant (11982) with the implant insertion (11981). In this case, Medicare will never pay for the two procedures at the same session. Therefore, no modifier can be used to override the edit.