Ob-Gyn Coding Alert

Note the 58542, 58558 modifier indicator change.

As is typical of the first round of edits for a new year, many of the new CCI 25.0 edits focus on the new code additions, changes, and revisions for CPT® 2019 you had to learn by the start of 2019, but you don’t have a lot of time to digest this news — these edits went into effect January 1.

Check out the new edits, the modifier indicator change, and deletions affecting ob-gyn practices like yours.

First, Pinpoint These Surgical Procedure Bundles

First of all, CCI 25.0 targets the new CPT^® additions for 2019.

FNA biopsy codes: CCI 25.0 adds new fine needle aspiration biopsy codes 10005, 10007, 10009 and 10011 as column 2 codes to the following ob-gyn codes.

Heads up: All of these edits have a modifier indicator of “1.” When the modifier indicator is “1,” this means that you may be able to report both codes of an edit pair under certain circumstances by using a modifier. For example, you can overcome the edit, if appropriate, with the use of a modifier such as modifier 59 (Distinct procedural service), explains Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

The surgeon has to sufficiently document that the image guided fine needle aspiration was a distinct service, says Melanie Witt, RN, MA,  an independent coding expert based in Guadalupita, New Mexico.

The column 1 codes are: vulvar biopsy (56605-+56606 and 56821), vaginal biopsy and vaginectomy (57100-57100, 57105, 57109, 57112 and 57421), cervical biopsy (57454-57455, 57460 and 57500), radical trachelectomy (57531), endometrial sampling (58100-58110), radical hysterectomy (58210 and 58548), hysteroscopic D&C (58558), ovarian biopsy (58900), oophorectomy and staging laparotomy for malignancy (58943 and 58960).

Skin biopsy codes: Additionally, CCI 25.0 bundles the new skin biopsy codes (11102-+11107) into the vulvar biopsy codes 56605-+56606. You can use a modifier to bypass this edit if appropriate.

Lymph node biopsy/excision: New code 38531 (Biopsy or excision of lymph node(s); open, inguinofemoral node(s)) has been permanently bundled with all of the radical vulvectomy codes 56631-56640. As the Medicare modifier indicator is “0,” you cannot use a modifier to bypass this edit.

Code 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C) is now bundled with three procedures, but with a modifier indicator of “1,” which permits billing if the criteria for bypassing the edit are documented. The three codes are:

• 58548 (Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed)
• 58553 (Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g)
• 58956 (Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy).

Update These New Ultrasound Codes with These Edits

Also, CCI 25.0 puts the spotlight on the following new ultrasound codes:

• 76978 (Ultrasound, targeted dynamic microbubble sonographic contrast charac­terization (non-cardiac); initial lesion),
• +76979 (… each additional lesion with separate injection (List separately in addition to code for primary procedure)),
• 76981 (Ultrasound, elastography; parenchyma (eg, organ)),
• 76982 (… first target lesion), and
• +76983 (… each additional target lesion (List separately in addition to code for primary procedure)).

This round of CCI edits bundles these codes with the following gyn ultrasound codes. They may, however, be billed in addition if they meet the requirement of being a “distinct procedure:”

• 76830 (Ultrasound, transvaginal)
• 76831 (Saline infusion sonohysterography (SIS), including color flow Doppler, when performed)
• 76856 (Ultrasound, pelvic (nonobstetric), real time with image documentation; complete)
• 76857 (Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)).

Evaluate These E/M Bundles

All of your E/M CPT^® codes now include the work represented by new psychological and neuropsychological codes (96130-96147), the new behavior and adaptive services codes (97151-97158), and collection and interpretation of physiologic data code 99091.

The modifier indicator is “1,” but remember that modifier 59 (Distinct procedural service) does not apply to E/M services. You will instead look to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to bypass the edit if the E/M service is separate and significant from the bundled services. These bundling edits apply as well to all of the preventive medicine codes even though Medicare does not pay for them.

Important: Decipher These Bundling Designation Changes

You may be used to the edit bundling 58542 (Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)) and 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C) — but CCI 25.0 changes that dynamic.

As of January 1, the modifier indicator changes from “0,” meaning you cannot separate the bundle under any circumstance, to “1,” meaning that you can. In other words, if the ob-gyn performed a hysteroscopic D&C prior to the laparoscopic supracervical hysterectomy, you could bill it with the addition of a modifier 59 (Distinct procedural service), Witt says.

Heads up: Keep in mind that the hysteroscopic procedure must meet the definition of a “distinct procedure,” Witt says. “Medicare, for instance, would view this a viable combination if the biopsy was done to determine whether it was appropriate to perform the supracervical hysterectomy if cancer was suspected.”

Don’t Forget These Deletions

You’ve got to strike through some old edits, too. You’ll find a myriad of ob-gyn edit deletions due to the deletion of the following three codes. Find out more:

• CPT^® deleted 76001 (Fluoroscopy, physician or other qualified health care professional time more than 1 hour, assisting a nonradiologic physician or other qualified health care professional (eg, nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy) due to low volume of utilization, reflecting current clinical practice.
• CPT^® deleted 64508 (Injection, anesthetic agent; carotid sinus (separate procedure)) but has no replacement code,
• CPT^® deleted 10022 (Fine needle aspiration; with imaging guidance) and replaced it with imaging specific codes 10005-+10012, which are now being bundled with select ob-gyn codes effective Jan. 1.