Ob-Gyn Coding Alert

"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

56350-51 Diagnostic hysteroscopy
625.3 Dysmenorrhea

57500-51 Cervical biopsy
617.1 Endometriosis of ovary

58350-51 Chromotubation of oviduct
617.1 Endometriosis of ovary

Codes 56303 and 56306 were reimbursed for this case; all of the other procedures were denied for lack of medical necessity. There were several problems with the coding that was submitted for this case:

Problem 1: The coder unbundled the hysteroscopy with D&C. When a single CPT code exists that describes a combination of procedures, it is not appropriate to separately bill each part of the procedure with an individual code. The unbundling occurred when the coder billed the hysteroscopy (56350) and the D&C (58120) separately. The correct code would be 56351 (hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C). The coder also has linked the procedures to ICD-9 code 625.3 (dysmenorrhea). This diagnosis lacks specificity and will likely not pass medical necessity edits for most payers.

Problem 2: The cervical biopsies were taken via a Pap smear, and as such, should not be billed individually using code 57500 (cervical biopsy). In addition, most payers will routinely deny separate payment for biopsies performed at the time of a procedure for other problems unless it can be shown that the biopsies were medically necessary and distinct from the primary surgery. In this case, the documentation does not support billing separately for the biopsies.

Problem 3: Code 56304 (laparoscopy with lysis of adhesions) should be used with caution. It should only be reported when adhesions are dense and obstructive and significant additional physician work is required to remove the adhesions to better visualize the pertinent anatomic structures. In this case, the adhesions were filmy in nature so the procedure should not have been reported. This code is also designated by CPT as a separate procedure, and would require a -59 modifier to be considered for payment. The - 59 modifier indicates that the procedure is distinct and separate from other procedures performed on the same day.

Another option when requesting supplementary reimbursement for lysis of adhesions would be to add modifier
-22 (unusual procedural services) to the primary surgical code, which will cause the claim to be set aside for manual review. If lysis of adhesions is to be billed, however, supporting documentation should always accompany the claim.

Problem 4: In this case, chromotubation was used at the end of the procedure to check the effectiveness of the surgical interventions and should not have been reported. This procedure should only be reported and coded when it is used to diagnose a problem that is then surgically corrected (either at this surgical session or at a later time).

Correct Coding for This Case

CPT
56303
56306-51
56351-51*

ICD-9
617.1
620.2

*Note: This procedure will probably be denied if linked to dysmenorrhea, 617.1, but the physician has not indicated another reason for doing the procedure."