Ob-Gyn Coding Alert

Some practices are beginning to offer the Essure implantation to their patients as a form of tubal ligation, but the question, as always with new procedures, is: "How should I code for this?"
 
The Essure micro-insert is a new tubal ligation device approved by the U.S. Food and Drug Administration that involves using a hysteroscope to place the insert into the proximal portion of each fallopian tube. When the device is released, it expands and anchors in the fallopian tube where it will cause tissue to form around the device that in a few months will block the tube, resulting in sterilization. The ob-gyn can perform the procedure in the office under local anesthesia or conscious sedation, and it takes approximately 35 minutes. The patient must stay on birth control until the doctor can perform a hysterosalpingogram (74740, Hysterosalpingography, radiological supervision and interpretation; and 58340*, Catheterization and introduction of saline or contrast material for hysterosonography or hysterosalpingography) after three months to verify that the tubes are blocked.
 
In the April Ob-Gyn Coding Alert, a Reader Question offered three coding possibilities for inserting this new device. Since then, several readers have commented that two of the coding solutions, which involved reporting the hysteroscopy separately, were not accurate. Consequently, we have decided to revisit the subject and discuss in more detail the pros and cons of each coding solution.

Examine the Procedure

On its face, the new procedure seems to be an occlusion of the fallopian tubes by a device through the vaginal canal. That would imply that you should use 58615 (Occlusion of fallopian tube[s] by device [e.g., band, clip, Falope ring] vaginal or suprapubic approach). But before deciding to report this code, you should know that CPT guidelines state that the code selected should accurately identify the service performed, not merely approximate the service provided.
 
So the first question to ask will be, "Is code 58615 substantially correct?" CPT created 58615 to report a vaginal or suprapubic surgical approach to occluding the fallopian tubes: that is, a colpotomy incision into the vaginal wall or making a small incision above the pubic bone. The Essure procedure, on the other hand, uses a hysteroscope to view the tubes to ensure that the ob-gyn can perform the procedure and then guide the insert's placement. The physician doesn't make a surgical incision.
 
From a pure theoretical standpoint, therefore, CPT does not provide a code for the Essure procedure, and the unlisted hysteroscopy code (58579, Unlisted hysteroscopy procedure, uterus) seems to be the only correct coding solution.
 
"In a perfect world where all payers accept unlisted-procedure codes, this might be true," says Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va. "Many of my clients have told me that their payers do not accept unlisted code numbers - they are asked to come up with an existing CPT code that is close. In this situation I would advise them to select 58615 and to consider whether or not to also bill separately for a diagnostic hysteroscopy based on the documentation."
 
On the other hand, "dealing with an unlisted-procedure code is not as difficult as it used to be," says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. If ob-gyns are commonly performing the procedure and there is available information about it (see www.essure.com), getting approval is not difficult, she adds. "An attached operative report and/or cover letter facilitate payment."

Adding the Hysteroscopy Still the Big Question

Choosing whether to report a hysteroscopy can be a tricky question with Essure. For instance, if the documentation supports that the ob-gyn performed a diagnostic exam before proceeding with the device's insertion to determine whether he could perform the procedure, you should bill the hysteroscopy separately because it represents a "different procedure," Witt says. In other words, you can correctly view the diagnostic hysteroscopy, which CPT designates as a "separate procedure," in this circumstance to represent a distinct procedure (and in this case, you would append modifier -59 [Distinct procedural service] to the separately reported 58555, Hysteroscopy, diagnostic [separate procedure]).
 
If, on the other hand, the physician uses the hysteroscope simply to guide the device into place, you would have to view the hysteroscopy as an integral part of the procedure and reporting it separately might be inappropriate, Witt notes. Code 58615, however, does not take into account any additional work that may be involved with inserting the hysteroscope.
 
You might argue that if the work involved with a surgical approach is equivalent to that of a hysteroscopic approach, your best coding choice would be 58615. But if using the hysteroscope is actually more work, then you would add modifier -22 (Unusual procedural services) to this code. Unfortunately, if the physician always elects to use modifier  -22 whenever reporting 58615, the payer may question that this is truly an "unusual" service for the provider and deny the request for additional payment, Witt says.
 
So you should weigh the proposed coding solutions to find the one that best suits the circumstance and documentation when your ob-gyn performs the procedure on a particular patient in your practice, Witt says. You also should contact your carriers to determine if they are willing to cover this new procedure and, if so, which coding solution they prefer for Essure.