Ob-Gyn Coding Alert

Ob/gyn surgeons perform a tubal ligation at the patient's request when she no longer wishes to conceive children. More and more women who have undergone the procedure are looking to tubal ligation reversal as a means of restoring their fertility.
 
Although coding and reimbursement for both procedures can vary from carrier to carrier, reimbursement and diagnostics for tubal ligation depend on whether the procedure was performed as part of another surgery or as an independent elective procedure.
 
When tubal ligation is performed separately from any other procedures or hospitalization, it is coded according to the method used to accomplish the procedure. For example, 58600 (ligation or transection of fallopian tube[s], abdominal or vaginal approach, unilateral or bilateral) and 58615 (occlusion of fallopian tube[s] by device [e.g., band, clip, Falope ring] vaginal or suprapubic approach) apply when a laparoscope is not used during the procedure; 58670 (laparoscopy, surgical; with fulguration of oviducts [with or without transection]) and 58671 (... with occlusion of oviducts by device [e.g., band, clip, or Falope ring]) apply when a laparascope is used.
 
Melanie Witt, RN, CPC, MA, an independent coding educator from Fredericksburg, Va., and an ob/gyn coding expert, says carriers that pay for tubal ligation are generally those that pay for birth control.
 
It is unlikely that a large health maintenance organization or preferred provider organization that does not cover birth control would pay for an elective surgery like tubal ligation.

Coding for tubal ligation accurately depends on 1) whether the procedure was performed after vaginal or cesarean delivery and 2) whether the physician performed the procedure immediately after the delivery (during the same operative session) or a day or more after the delivery (during the same hospital stay).
 
Vaginal Delivery. Tubal ligation is coded separately when billed with any of the following:

 

59400 routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
 

59409 vaginal delivery only (with or without episiotomy and/or forceps)
 

59410 ... including postpartum care.

If the tubal ligation occurs immediately after the delivery (during the same operative session), use 58605 (ligation or transection of fallopian tube[s], abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization [separate procedure]) with modifier -59 (distinct procedural service) appended. Modifier -59 tells the carrier that the tubal ligation was a distinct service from the delivery even though they occurred during the same session. Since the tubal ligation requires a separate incision and is essentially unrelated to the vaginal delivery, carriers that pay for the ligation under other circumstances will generally not take issue with reimbursement using this coding sequence.
 
If the tubal ligation occurs a day or more after the delivery (during the same hospital stay), use 58605 with modifier -79 (unrelated procedure or service by the same physician during the postoperative period).
 
Note: Some carriers may pay less for tubal ligation when reported with modifier -59, reasoning that the prep work has already been done for the patient prior to delivery and that there is no need to pay twice for the same work. Coders appending modifier -79 should receive full payment for the procedure.
 
Cesarean Delivery. Cesarean delivery frequently offers the surgeon the chance to perform tubal ligation immediately after the delivery, sparing the patient an additional surgical session. Use 58611 (ligation or transection of fallopian tube[s] when done at the time of cesarean delivery or intra-abdominal surgery [not a separate procedure] [list separately in addition to code for primary procedure]) in this case.
 
Billing for tubal ligation at the time of cesarean is almost always a problem with carriers, however, that reason that since the incision is already made, doing the ligation at the same time does not represent significant effort for the physician. Although the American College of Obstetricians and Gynecologists (ACOG) specifically leaves tubal ligation off the list of bundled procedures in its policy on cesarean deliveries and global ob care with cesarean, some carriers will pay little or no extra for the procedure. Tubal ligation performed at the time of cesarean delivery can prove a significant source of revenue, so practices should negotiate contract renewal to see that the procedure is reimbursed separately from the global package or cesarean delivery codes.
 
Note: Tubal ligation is always diagnosed as V25.2 (sterilization), no matter which type of tubal ligation is performed.

Tubal ligation reversal is an increasingly common and successful procedure, with up to 80 percent of surgeries leaving little or no damage to tube remnants. The patient's age, the technique used and whether one or both fallopian tubes are rejoined during the surgery factor into the chances for a successful tubal ligation reversal.
 
Gary S. Berger, MD, FACOG, medical director of the Chapel Hill Fertility Center in Chapel Hill, N.C., has performed more than 2,000 outpatient tubal ligation reversals since the mid-1990s. The in-office procedure takes less than one hour and has a shorter recovery time than traditional inpatient tubal ligation reversals.
 
Berger's staff codes the tubal ligation reversal as 58750 (tubotubal anastomosis). With some surgeries," says Berger, "when there is no open tubal lumen present on the uterine side, a tube has to be implanted into the uterus." When this happens, use 58752 (tubouterine implantation) rather than 58750. The accompanying ICD-9 code for the surgery is V26.0 (tuboplasty or vasoplasty after previous sterilization). As this represents the only reason for the surgery, this is one time that the V code is the primary diagnostic code. 
 
"Coders also need to remember that both of these codes are unilateral codes," Witt adds. When Berger performs the anastomosis or implantation on each side, modifier -50 (bilateral procedure) is used with the code selected.
 
Surgeons who perform the procedures must transfer the cost to the patient because most insurance companies will not pay for 58750 or 58752. "Because of the difficulties in dealing with insurance carriers," says Berger, "we require payment by the patient and then have the patient file for reimbursement directly to them even if they have coverage."