Ob-Gyn Coding Alert

Find out which edits are mutually exclusive and which won't allow a modifier

Twenty-seven is the key number for this round of National Correct Coding Initiative (NCCI) edits. That's the number of ob-gyn-quot;related edits you-ve got to implement to your daily coding practice -- and sooner rather than later. They took  effect April 1.

Pelvic Exam Code Hit Again

Remember how NCCI version 13.0 slammed 57410 (Pelvic examination under anesthesia) with edits? NCCI 13.1 brings you a few more.

Many of the cystourethroscopy codes and the few remaining codes in the female genitourinary chapter that did not include this bundle already -- such as colpopexy (57283, Colpopexy, vaginal; intraperitoneal approach [uterosacral, levator myorrhaphy]) and vaginal graft revision (57295, Revision [including removal] of prosthetic vaginal graft; vaginal approach) -- now include the work involved with a pelvic exam under anesthesia (57410).

Watch out: CMS has placed a -0- indicator on these bundles. This means you cannot use a modifier to bypass the edit under any circumstance, says Melanie Witt, RN, CPC-OGS, MA, a coding expert based out of Guadalupita, N.M.

-This shouldn't be a big surprise, because payers always bundle an exam under anesthesia (EUA) when documented in an op report,- Witt says.

Grapple With These Vaginal Graft Edits

Second, when you prepare to report vaginal graft revision code 57295, you-ll need to take a few additional bundles into account.

Modifier indicator of -0-: NCCI edits now include catheter placement and perineoplasty codes 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]), 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) and 56810 (Perineoplasty, repair of perineum, nonobstetrical [separate procedure]) with 57295. In other words, you should not try to report these procedures separately from a vaginal graft revision.

Modifier indicator of -1-: NCCI gives a modifier indicator of -1- to the following edits bundling procedures into 57295. These procedures include vaginal procedures for a biopsy (57100, Biopsy of vaginal mucosa; simple [separate procedure]), foreign-body removal (57415, Removal of impacted vaginal foreign body [separate procedure] under anesthesia), application of packing (57180, Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage [separate procedure]), vaginal dilation (57400, Dilation of vagina under anesthesia) and vaginal and cervical colposcopy (57420, Colposcopy of the entire vagina, with cervix if present; and 57452, Colposcopy of the cervix including upper/adjacent vagina).

To separately report these procedures from the vaginal graft revision, you would append a modifier, such as 59 (Distinct procedural service), to the component procedure code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs at the American Academy of Professional Coders.

In addition, NCCI bundles a few other codes into 57295 simply because they are CPT -separate procedures,- Witt says. They include:

- 57500 -- Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)

- 58100 -- Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation,
any method (separate procedure)

- 57800 -- Dilation of cervical canal, instrumental (separate procedure).

Don't miss: You-ve got a few mutually exclusive edits to contend with. Mutually exclusive edits pair procedures or services that the physician could not reasonably perform during the same session on the same beneficiary. If you were to report two mutually exclusive codes for the same patient during the same session, Medicare would reimburse only for the lesser-valued procedures.

You should now consider vaginal graft revision (57295) a mutually exclusive procedure when you try to bill with the codes for construction of an artificial vagina (57291-57292). The indicator is -1,- but -I can think of no instance when you would be removing a graft and then constructing an artificial vagina -- that situation would be a rare thing indeed,- Witt says.

Fine Tune How You Code 11900-11901

Heads up: CMS tweaks the way you-ll report 11900 (Injection, intralesional; up to and including seven lesions) and 11901 (- more than seven lesions). NCCI bundles these codes into all of the chemotherapy injection codes (96401-96425). Although these edits have an indicator -1,- the -only way to bill this combination is if the injection
was not related to the reason for the chemotherapy being given for a specific site of cancer,- Witt says.

Also, NCCI bundles 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) into 90774 (... intravenous push, single or initial substance/drug), based on what CMS calls -HCPCS/CPT coding manual instruction/guideline.-

CPT does not indicate that you-re forbidden to bill these together, so CMS will allow you to bypass this edit. But the chances of this edit substantially impacting ob-gyn practices are unlikely. -Most of the IV push drugs are for really serious illnesses that a normal ob-gyn would not be treating,- Witt says.

To bypass the edit, you would have to show that this was a different patient encounter or a different drug that required the different mode of administration, Witt says.

Update Your Ultrasound Coding Practice

The next edit shouldn't come as a big surprise. Code 76830 (Ultrasound, transvaginal) is now bundled into 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed). 

Rationale: -Although this bundle also has a -1- indicator, the use of a transvaginal probe is a normal part of the SIS procedure to obtain a result. Therefore, to bill this combination, your ob-gyn's documentation would need to demonstrate a different patient session,- Witt says.

New Code Necessitates More Edits

The new code G0394 (Blood occult test [e.g., guaiac], feces, for single determination for colorectal neoplasm [e.g., patient was provided three cards or single triple card for consecutive collection]) is the subject of many mutually exclusive edits. This code is now mutually exclusive to all other fecal-occult blood tests. 

Because NCCI assigns the edits a -0- modifier indicator, payers would never reimburse a second screening test performed on the same day.

Tip: -You should remember that when the patient is given the cards to take home, they are billed when the cards are returned -- not on the day they are given to the patient,- Witt says.

Be Careful With Excision or Destruction Codes

The two codes for cyst or endometrioma excision or destruction (49200, Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas; and 49201, - extensive) have some additional bundles that you-ll have to watch out for.

These two codes will now include the work represented by:

 - 58700 -- Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)

 - 58720 -- Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)

 - 58805 -- Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach

 - 58900 -- Biopsy of ovary, unilateral or bilateral (separate procedure).

Rationale: Again, -because each of these is a CPT -separate procedure,- Medicare will not allow you to use a modifier to bypass these edits,- Witt says.