Ob-Gyn Coding Alert

You may not be able to use a modifier to bypass the majority of them.

The Correct Coding Initiative (CCI) version 20.3 version brings lots of new bundles for ob-gyn practices. More than 30 bundled codes are now part of a large group of primary codes reported by ob-gyns. That means if you want to avoid denials, you’ve got to be aware of these numerous changes— and fast. They went into effect October 1, 2014. 

Warning: “The majority of these bundled codes cannot be bypassed by using a modifier – they are permanently bundled,” says Melanie Witt, RN, CPC, COBGC, MA, an independent coding consultant in Guadalupita, N.M. “You can secure additional reimbursement if the documentation clearly warrants the use of modifier 22 (Increased procedural services) on the primary code for the additional work involved in the bundled procedure.”

Heads Up on This Hysteroscopy Bundle

Code 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C) is now bundled with the codes for hysteroscopic removal of a fibroid (58561) and the removal of an impacted foreign body (58562). “This is the one code bundle that will have the greatest impact on ob-gyn practices, since the D&C is commonly performed at the time of these two procedures,” Witt warns. 

However, “CMS has indicated that no modifier will be allowed to bypass these bundles, so be sure that your physician has adequately documented the medical need for a D&C with this procedure for this patient, and fully describes the amount of work and time it took to perform it in order to warrant the addition of a modifier 22 (Increased procedural services),” Witt adds.

Prepare For This 57260 Headache

Codes 57210 (Colpoperineorrhaphy, suture of injury of vagina and/or perineum [nonobstetrical]) and 57260 (Combined anteroposterior colporrhaphy) are being bundled into 32 primary codes, and you can bypass all but one of the bundles with the appropriate modifier. Code 57210 is permanently bundled into 58145 (Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach). The remainder of the affected primary codes are 57220, 57250-57268, 57295, 57320, 57550, 57720, 58260-58294, 58550-58554, 58605-58615, and 58820.

Heads up: You’ll find a lot of problems “regarding the particular edit that bundles 57260 (A&P) repair with all vaginal and LAVH hysterectomies with a ‘0’ indicator,” Witt warns. “The American Congress of Obstetricians and Gynecologists (ACOG) says they and the American Urogynecologic Society (AUGS) wrote to CMS in May in regard to these edits and objected to them strongly — and despite this, they decided to go ahead,” Witt explains. 

What to do: Therefore, you should be billing each of these combinations with a modifier 22 and stress to your physicians that they need to provide complete documentation including the separate medical indication for the A&P as opposed to the hysterectomy, Witt says. “You can also have your physicians write letters to CMS, their local Medicare medical directors, and have them also write to their state and local representatives regarding this issue. If they do not get involved, the bundle will probably not go away.”

Update How You Report Ultrasound Codes

In the area of ob ultrasound, you can override the new edits with an appropriate modifier (such as, 59, Distinct procedural service), but be sure your documentation supports using a modifier before you bill.  

For this version, code 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited [e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], 1 or more fetuses) is bundled into the following codes: 

• 76813 (Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation), 
• 76821 (Doppler velocimetry, fetal; middle cerebral artery), 
• 76825 (Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording) and 
• 76826 (Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study).

Also, note that codes 76827 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete) and 76828 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study) are bundled into 76185. “This is because these two ultrasound codes have fewer RVUs than code 76815,” Witt says. 

A final edit relates to the bundling of 93325 (Doppler echocardiography color flow velocity mapping [List separately in addition to codes for echocardiography]) into 76820 (Doppler velocimetry, fetal; umbilical artery) based on the CPT® instruction that you can only use 93325 with echocardiographic procedures.

Examine These Excision of Cervical Stump Edits

You will have 27 codes that will be affected by 2 mutually exclusive bundling edits, but remembering them will be fairly straightforward.  

The codes 57550 (Excision of cervical stump, vaginal approach) and 57555 (Excision of cervical stump, vaginal approach; with anterior and/or posterior repair) have been bundled into most of the hysterectomy codes. No modifier can be used to bypass these edits. The code ranges impacted are: 

• the abdominal hysterectomy codes 58150-58210, 
• the vaginal hysterectomy codes 58260-58262 and 58290-58291, 
• the laparoscopic supracervical hysterectomy codes 58541-58544, 
• the laparoscopic radical hysterectomy code 58548, 
• the LAVH codes 58550-58554, 
• the total laparoscopic hysterectomy codes 58570-58573, and 
• the cancer removal codes that include hysterectomy 58951, and 58953-58956.

No Modifier Applies To These 57531 Edits

Code 57531 (Radical trachelectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling biopsy, with or without removal of tube(s), with or without removal of ovary(s)) has been assigned some new bundled services to include codes for different types of lymph node removal, and more general codes for exploration.  

The bundled codes now include the lymphadenectomy codes 38562, 38564, 38570 and 38765, as well as the exploration codes 49000, 49010 and 57000.  Each of these bundles has been assigned a “0” indicator, which means you cannot use a modifier to bypass the edit.

Check Out These 49XXX Edits

Code 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing [separate procedure]) is bundled into code 58970 (Follicle puncture for oocyte retrieval, any method), and 59150-59151 (Laparoscopic treatment of ectopic pregnancy). As with many of the bundles in this version, you cannot use a modifier to bypass the edit.

Code 49400 (Injection of air or contrast into peritoneal cavity [separate procedure]), is another CPT® “separate procedure” that has been bundled into 35 ob-gyn codes. These edits have a “0” modifier indicator, meaning no modifier can be used to bypass the edits. The primary codes affected are 49320-49327, 51990-51992, 57423-57426, 58541-58552, 58553-58554, 58570-58662, 58640-58673 and 59150.

Your 57XXX Codes Receive a Slew of New Edits

You’ll find that 57000 (Colpotomy; with exploration) is bundled into 26 ob-gyn codes and carries a “0” indicator. “That means that colpotomy with exploration cannot be billed with any of the listed procedures,” Witt says. The affected codes are: 57267, 57295, 57300, 57550-57556, 57720, 58260-58294, 58548, 58600 and 58820. Also, this code is bundled into 58605 (Ligation or transection of fallopian tube[s], abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization [separate procedure]) and 58615 (Occlusion of fallopian tube(s) by device [e.g., band, clip, Falope ring] vaginal or suprapubic approach). However, you can use a modifier to bypass these bundles if supported by the documentation.

CCI 20.3 bundles 57010 (Colpotomy; with drainage of pelvic abscess) into three of the tubal ligation codes (58600-58615) but offers the possibility of a modifier to bypass the edit, if warranted.

Code 57100 (Biopsy of vaginal mucosa; simple [separate procedure]) is bundled into 18 codes, and the majority of the bundles do not allow for a modifier to bypass the edits. The exceptions are two tubal ligation codes (58600 and 58605). The primary codes that do not allow for separate billing of 57100 include 57267, 58260-58294, 58615 and 58820.

Code 57105 (Biopsy of vaginal mucosa; extensive, requiring suture [including cysts]) is bundled into 28 codes with the majority of them carrying a “0” indicator. That means you cannot bypass these edits. The primary codes that permanently bundle 57105 are 58260-58294, and 58550-58554. The primary codes that will allow a modifier to be used to bypass this bundled service include 57267-57268, 57300, 57320, 57550-57555, 57720, 58600-58615, and 58820.

Code 57106 (Vaginectomy, partial removal of vaginal wall) is bundled into the following codes and no modifier can be used to bypass the edits: 57555, 58262-58270, 58291-58294, and 58550-58554.

Code 57150 (Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease) is bundled into 24 ob-gyn codes, and you cannot use a modifier to bypass the edit. The code ranges affected are: 57300, 57550, 57720, 58260-58294, 58550-58554, 58600-58615 and 58820.

You’ll also find that 57180 (Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage [separate procedure]) is being permanently bundled into the codes for a tubal ligation (58600-58615), drainage of an ovarian abscess (58820), and insertion of Heyman capsules (58346).

CCI 20.3 bundles 57280 (Colpopexy, abdominal approach) into 18 primary ob-gyn codes, and you cannot use a modifier to bypass the edit. The codes that 57280 is bundled into include 57545, 58260-58294, and 58550-58554.

Code 57282 (Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)) is bundled into 17 primary ob-gyn codes, and once again, you cannot use a modifier to bypass the edit. The affected codes are 58260-58294 and 58550-58554.

CCI 20.3 permanently bundles 57283 (Colpopexy, vaginal; intra-peritoneal approach [uterosacral, levator myorrhaphy]) into 12 primary ob-gyn codes including 58260-58262, 58267, 58275, 58285-58291, and 58550-58554.

Code 57284 (Paravaginal defect repair [including repair of cystocele, if performed]; open abdominal approach) is bundled into 17 primary ob-gyn codes, and this bundle cannot be bypassed using a modifier. The affected codes are 57454, 58260-58263, 58270-58294, 58550-58554.

Code 57505 (Endocervical curettage [not done as part of a dilation and curettage]) is bundled into 45 gynecological and obstetric procedures, and you cannot bypass the bundles with a modifier. The affected codes are 51925, 58150-58294, 58541-58544, 58548-58554, 58570-58573, 58951-58956, 59160, 59812-59841, and 59870.

Other permanently bundled edits include: 

• Code 57530 (Trachelectomy [cervicectomy], amputation of cervix [separate procedure]) into the abdominal hysterectomy code 58150
• Code 57555 (Excision of cervical stump, vaginal approach; with anterior and/or posterior repair) into the partial vaginectomy codes 57107 and 57109.
• Code 57558 (Dilation and curettage of cervical stump) into 34 ob-gyn codes including 58150-58210, 58260-58294, 58541-58554, 58570-58573, 58951, and 58956
• Code 57800 (Dilation of cervical canal, instrumental [separate procedure]) into the code for IUD removal (58301) and postpartum curettage (59160)
• Code 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) into 22 primary codes including 51925, 58541-58554, 58570-58573, 59160, 59812-59841, and 59870.

Don’t Miss These New 58XXX Bundles

Because Medicare does not allow the removal of fibroids to be billed separately from a hysterectomy, it should be no surprise that many of the myomectomy codes are now being bundled into procedures that include a hysterectomy.

You’ll find that 58140 (Myomectomy, excision of fibroid tumor[s] of uterus, 1 to 4 intramural myoma[s] with total weight of 250 g or less and/or removal of surface myomas; abdominal approach) is now bundled into 59135 (Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy). You cannot use a modifier to bypass this edit.

Code 58146 (Myomectomy, excision of fibroid tumor[s] of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach) is now permanently bundled into 58953-58954 and 59135.

Codes 58545 (Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas) and 58546 (Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g) are bundled into code 58951-58954. You cannot use a modifier to bypass the edit.

Finally, CCI 20.3 permanently bundles 58561 (Hysteroscopy, surgical; with removal of leiomyomata) into 58150-58240, 58548, 58951-58954 and 58956.