"Editors Note: This months case is a good example of how an inexperienced coder can place an ob/gyn practice in jeopardy, through frequent unbundling. After receiving a denial for this case, the practice soon was audited for other possible coding and billing violations.
Clinical Situation
The patient is a 25-year-old female, gravida 1, para 0, who presents with complaints of moderate dysmenorrhea, which starts approximately one day prior to the onset of menses and continues through cycle day number three. On hysterosalpingogram, no filling defects were detected; however, loculation of dye was noted around the left fallopian tube, which is suggestive of pelvic adhesions.
Summary of Ob/Gyns Operative Note
1. Preoperative Diagnosis: Moderate dysmenorrhea with suggestion of peritubal adhesion on hysterosalpingogram.
2. Postoperative Diagnosis: Mild endometriosis, pelvic congestion syndrome, pelvic adhesive disease, left ovarian cyst, and cervical dysplasia.
3. Procedures: Pap smear, hysteroscopy, fractional dilation and curettage, cervical biopsies (times two), operative laparoscopy, laser ablation of endometriosis, laser lysis of adhesions, left ovarian cyst aspiration, and chromotubation.
The operative note indicates that the adhesions and endometriosis (in the ovarian fossa) were lysed via laser, but that the adhesions were filmy in nature. In addition, an ovarian cyst was noted and was aspirated during the procedure. Two separate specimens were taken during the Pap smear for biopsies. The physician used chromotubation to check for patency at the end of the procedure.
Terminology and Procedures
The patient is having dysmenorrhea (painful menstruation) which can be associated with endometriosis or adhesions. Endometriosis occurs when part of the menstrual endometrium passes into the peritoneal cavity. Adhesions may be due to previous surgery or to an infective process. Additionally, the patient was found to have an ovarian cyst (a collection of fluid within a sac). Because it is difficult to distinguish between a benign or malignant growth in the ovary without doing a pathological examination, resection of the cyst is necessary.
Treatment for this patient included using a laser to destroy the endometriosis, aspirating the ovarian cyst and using chromotubation to check for tubal patency.
Coders Notebook
The coder used the following CPT and ICD-9 codes to bill for these procedures:
56303 Laparoscopic fulguration of endometriosis
617.1 Endometriosis of ovary
56306-51 Laparoscopic aspiration (of ovary)
620.2 Ovarian cyst
56304-51 Laparoscopic lysis of adhesion
614.6 Pelvic adhesions
58120-51 Dilation and curettage
625.3 Dysmenorrhea
