Ob-Gyn Coding Alert

The American Medical Associations 2001 CPT, released Nov. 1, contains several important changes for ob/gyn providers and their coders. Although the new and revised codes will not go into effect until Jan. 1, 2001, ob/gyn practices will want to be sure they are ready for the changes

This year CPT presents us with some minor revisions to the evaluation and management [E/M] section. There are also some very needed changes in the surgical and ultrasound sections, which will be of the most interest to ob/gyns, says Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator. Additionally, there are changes to laboratory codes as well as some new modifiers that ob/gyns should be aware of.

Evaluation and Management Clarifications

In its introduction to the E/M guidelines, CPT has clarified that professional services when determining whether a patient is new or established to a practice must be face-to-face. Prior to this year, many payers strictly interpreted the definition of an established patient to mean a patient who had received any professional service in the past three years, Witt notes. Therefore, had a physician written a prescription for a patient whom he or she had not yet seen in the office, or had the physician talked to the patient on the phone prior to making an appointment (and this was documented in the record), many payers would claim that the patient was established to the practice. With this new clarification, providing either of these services would not prevent the physician or nonphysician practitioner (i.e., physicians assistant, nurse practitioner or certified nurse midwife) from billing a new patient visit when the patient first presents in the office for care.

The guidelines for use of critical care codes 99291 (critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (... each additional 30 minutes [list separately in addition to code for primary service]) have once again been revised after an extensive reworking in 1999. The latest revision stresses that to bill critical care codes the physician must be caring for a patient with a high probability of imminent or life-threatening deterioration in his or her condition due to single or multiple vital organ system failure. In addition, treatment for the illness or condition must involve procedures that deal with the organ system failure or life-threatening complications. A physician may bill for critical care and other E/M services on the same service date, but may not count the time spent performing other separately reported services or procedures as critical care time. Although it may be rare that ob/gyns bill for critical care services, there are times when it would be appropriate, such as when a patient with severe eclampsia experiences seizures. In this case, the ob/gyn who is caring for the patients condition would most likely be able to meet the revised criteria.

For those ob/gyns who provide care plan oversight services (which is sometimes necessary in cancer cases), the code definitions have been revised to clarify that communication (including telephone calls) with other physician and nonphysician healthcare professionals should be used solely to assess the patients condition or communicate decisions regarding the patients care. Remember, Witt adds, these codes may be billed only once per calendar month [they are selected based on the total time spent on oversight activities during the month], and may be billed only by the physician responsible for the care plan oversight.

Care plan oversight codes 99374-99380 may be billed in addition to E/M services provided for reasons other than oversight. If, for example, an E/M service is provided for a complaint of pelvic pain unrelated to the patients breast cancer (the reason for the care plan oversight), and if there are two or more diagnoses (e.g., 625.9, unspecified symptom associated with female genital organs) along with the ongoing diagnosis code for care oversight, both services are billable separately. Nevertheless, you will probably have to add modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the problem E/M service to show that it is significant and separately identifiable from the oversight.

Revisions and Additions to Surgical Procedures

Revisions and new code additions in the surgical section of CPT should assist physicians to report their procedures more accurately.

The breast surgery codes have been revised to differentiate more clearly between an open biopsy or a breast lesion excision from a percutaneous or needle core biopsy. Additionally, two new codes have been added.

The revised codes are:

19100 biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure); and

19101 biopsy of breast; open, incisional.

The new codes are:

19102 biopsy of breast; percutaneous, needle core, using imaging guidance; and

19103 biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance.

The codes now differentiate between biopsies using image guidance and those that do not. Prior to this, there was no code to record the additional equipment and technical training required to use the imaging equipment.

Other minor code changes to this section include revisions to excision codes 19120, 19125 and 19126.

Three new laparoscopic codes have also been added:

50947 laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement;

50948 laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement; and

50949 unlisted laparoscopy procedure, ureter.

Witt explains that 50947 and 50948 describe the creation of a new ureter implant site on the bladder when an obstruction occurs at the site where the ureter normally connects to the bladder. These procedures are typically performed on children and, as such, would not be reported by a gyn urologist except perhaps if he or she acted as an assistant to another physician. The unlisted code was added to complete the list of unlisted laparoscopic procedure codes specific to an anatomic site.

Long-awaited New Codes

Four code additions have finally appeared after many appeals from ob/gyn practitioners and coders. Prior to these additions, ob/gyn coders had to use 58999 (unlisted procedure, female genital system [nonobstetrical]) when coding several of these services. The new codes not only state explicitly what procedure the ob/gyn surgeon performed but also remove the ambiguity and accompanying reimbursement problems that go hand in hand with unlisted codes.

57022 incision and drainage of vaginal hematoma; postobstetrical

57023 incision and drainage of vaginal hematoma; non-obstetrical (e.g., post-trauma, spontaneous bleeding)

Code 57022 is used during the postpartum period, while 57023 is applicable in the cases described in the code and for the formation of a hematoma following vaginal surgery.

A third code was added to report the removal or revision of a previous sling procedure that has caused the patient to experience, for example, persistent urinary retention or obstruction and pain. The material used to suspend the urethra during the sling procedure is removed or mobilized to eliminate the problem.

57287 removal or revision of sling for stress incontinence (e.g., fascia or synthetic)

A fourth code addresses more specific coding for a thermal balloon ablation (also referred to as uterine balloon therapy or UBT).

58353 endometrial ablation, thermal, without hysteroscopic guidance

This code would be reported when endometrial ablation is performed without hysteroscopy to remove the uterine lining. The procedure involves brief suction curettage followed by the introduction of a balloon catheter into the uterus, which is then filled with a 5 percent solution of dextrose in water and heated to a temperature of 188 degrees Fahrenheit for about eight minutes, Witt explains. The heat thins the uterine lining, which will be sloughed off after the procedure. If hysteroscopy were performed either just before or during the ablation procedure, 58563 [hysteroscopy, surgical; with endometrial ablation (any method)] would be reported instead.

CPT has also revised four of the ovarian malignancy codes (58943-58960) to clarify that they may be used for tubal and primary peritoneal malignancy as well as ovarian malignancy.

58943 oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy

58950 resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy

58952 resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors)

58960 laparotomy, for staging or restaging of ovarian, tubal or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy

Code 58952, used to report radical debulking (reduction of tumor masses), more clearly defines the procedure as a radical excision or destruction of intra-abdominal or retroperitoneal tumors. If a debulking procedure is performed in the absence of ovarian, tubal or primary peritoneal cancer, 49200 (excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas;) or 49201 (... extensive) would be reported instead.

Although ob/gyns may not perform breast radiologic procedures, the changes to two of the current codes for stereotactic localization and guidance while placing a needle localization wire are worth noting for physicians ordering these procedures. Code 76095 (stereotactic localization guidance for breast biopsy or needle placement [e.g., for wire localization or for injection], each lesion, radiological supervision and interpretation), reported when computer-aided x-ray equipment is used to locate the tissue to be sampled, now more clearly describes the nature of the service as guidance for either a breast biopsy or needle placement. Code 76096 (mammographic guidance for needle placement, breast [e.g., for wire localization of for injection], each lesion, radiological supervision and interpretation) describes a mammogram used to guide the placement of the needle prior to biopsy. If either the radiologist or another physician performs the biopsy, 19100, 19102, 19103 or 88170 (fine needle aspiration; superficial tissue [e.g., thyroid, breast, prostate]) would also be reported. The surgeon or radiologist would code separately for the placement of the needle localization wire described by 19290 (preoperative placement of needle localization wire, breast) and 19291 (preoperative placement of needle localization wire, breast; each additional lesion).

Clarification for BPPs

Ob-gyns will be especially interested in the revised and new codes for fetal biophysical profile (BPP). CPT 2001 has added language to the existing code 76818 (fetal bio-physical profile; with non-stress testing) to clarify that the biophysical profile includes a fetal nonstress test (NST). Prior to this, some coders were submitting billing for both the BPP and NST and having both rejected.

Although not explicitly stated in previous editions of CPT, the BPP has always included the NST as a standard procedure. A new code, 76819 (fetal biophysical profile; without stress or non-stress testing), was added to describe a more limited BPP that does not include either stress or nonstress testing of the fetus. Note, however, that both BPP codes include measurement of fetal breathing movements (one or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes), fetal movement (three or more discrete body or limb movements within 30 minutes), fetal tone (one or more episodes of extension of a fetal extremity with return to flexion) and quantitation of amniotic fluid volume. In those cases in which only an amniotic fluid volume is performed, a limited ultrasound (76815, echography, pregnant uterus, B-scan and/or real time with image documentation; limited [fetal size, heart beat, placental location, fetal position, or emergency in the delivery room]) should be reported instead.

CPT 2001 also includes revisions to the ultrasound guidance codes by replacing the term radiological with the term imaging to more accurately reflect current technology and terminology. In addition, 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) was revised to clarify that ultrasound guidance is for needle placement rather than for the biopsy. Finally, the terminology for 76950 (ultrasonic guidance for placement of radiation therapy fields) and 76986 (ultrasonic guidance; intraoperative) was updated to replace the term echography with ultrasound guidance. The term B-scan was removed from 76950 to reflect that radiation therapy fields are all performed via this method. Therefore, 76960 which described placing the therapy fields using other than B-scan echography was deleted.

For obstetricians who must determine fetal lung maturity, CPT lists more than one method. In addition to the existing codes 83661 (fetal lung maturity assessment; lecithin sphinogomyelin [L/S] ratio) and 83662 (... foam stability test), there are two new codes. Physicians may now choose fluorescence polarization (83663) or lamellar body density (83664) methods to assess fetal lung maturity. These tests are performed on amniotic fluid.

There are many revisions to existing microbiology codes, but experts agree that only 87110 (culture, chlamydia, any source) will be of interest to ob/gyns. The only change to this code is to clarify that the chlamydia culture can come from any source.

The new code 89321 is used to report semen analysis for the presence and/or motility of sperm, but would not be reported by an ob/gyn. Instead, the purpose of the code is to report the presence of sperm following a vasectomy.

New Modifiers

CPT 2001 includes new modifiers that ob/gyns may use under certain circumstances.

Modifier -60 (altered surgical field) has been added to denote the presence of a more complicated surgical setting than might be considered normal. According to CPT, this modifier will tell the insurer that the primary surgery billed was significantly more complicated because of the effects of prior surgery, marked scarring, adhesions, inflammation, or distorted anatomy, irradiation, infection, very low weight (i.e., neonates and small infants less than 10 kg) and/or trauma (as documented in the patients medical record). This modifier should be useful to ob/gyns trying to receive payment for the lysis of extensive adhesions or anatomic distortions that resulted from a previous gynecologic surgery. Modifier -60 will be added to the primary procedure affected by the adhesions or distortions, and a higher fee should be charged to compensate for the significant additional work or complexity.

Note that modifier -22 (unusual procedural services), which has until now been used to show additional work for lysis of adhesions when submitting claims to Medicare and some private payers that automatically deny lysis of adhesions when coded separately, should no longer be used for this purpose. Modifier -22 is now reserved for those circumstances in which the procedure was unusual, but not for the reasons that apply to modifier -60. For instance, the physician would continue to use modifier -22 to describe a twin or triplet pregnancy global package (for documented significant additional work), but could also use this modifier in the case of tumor debulking that was more extensive than usual for the primary surgeon.

Modifier -22 may still apply to lysis of extensive adhesions, but only when the adhesions were not due to previous surgery, inflammation, trauma or irradiation (coders will have to check with the surgeon for case-by-case details). Modifier -22 might also be added to a procedure that was more difficult because of obesity in the patient.

Note: Due to a typographical error, modifier -60 is not listed in the surgery guidelines section or inside cover of CPT 2001, but is fully described in Appendix A. This oversight will be corrected in CPT 2002 and the modifier will be listed immediately following modifier -59 in the surgery guidelines section. Coders may wish to update their CPT 2001 books to remind themselves that modifier -60 is to be used exclusively with surgical procedure codes.

Lastly, a new modifier that applies only to ambulatory surgery center hospital outpatient services was added. Modifier -27 (multiple outpatient hospital E/M encounters on the same date) is not to be used by physicians, but only by the facility that reports the multiple services.