Ob-Gyn Coding Alert

Your options for reporting nuchal translucency just expanded -- here's how

If you-ve been holding your breath for codes to represent the latest in laparoscopic hysterectomy procedures and nuchal translucency measurements during pregnancy's first trimester, get ready to exhale.

CPT 2007 brings a slew of changes to ob-gyn coders, and you-ve got to learn them by Jan. 1.

Cheer for 2 Laparoscopic Hysterectomy Additions

CPT 2007 brings much-needed codes to supracervical laparoscopic hysterectomies as well as laparoscopic radical hysterectomies.

In the past: If an ob-gyn performed a supracervical laparoscopic hysterectomy in 2006, you only had two coding options:

- report one of the codes for a laparoscopically assisted hysterectomy (58550-58554) with modifier 52 (Reduced services) because the ob-gyn did not remove the cervix, or

- report the unlisted-procedure code 58578 (Unlisted laparoscopy procedure, uterus). 

As of Jan. 1: Now you have four new codes to accurately report this procedure:

- 58541 -- Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

- 58542 -- - with removal of tube(s) and/or ovary(s)

- 58543 -- Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g

- 58544 -- - with removal of tube(s) and/or ovary(s).

-This is great news, because the new codes will help cut down on all the documentation we-ve been sending to get reimbursed,- says Maureen Murphy, coding specialist at Mt. Kisco Medical Group in New York.

Watch out: CPT has gotten very specific about additional codes that you should not report with these procedures. These include 49320, diagnostic laparoscopy; 57410, exam under anesthesia; 58140, abdominal approach myomectomy; 58150, total abdominal hysterectomy; 58661, laparoscopic removal of tube(s) and or ovary(s); or 58670-58671, laparoscopic tubal ligation procedures.

Don't miss: If you-re looking to see if laparoscopic myomectomy codes are among those listed that you should not report in addition to the new codes, you won't find them -- but that doesn't mean you can report them. -CPT has clarified that this was an oversight on their part when the book went to print,- says Melanie Witt, RN, CPC-OGS, MA, an ob-gyn coding expert based in Guadalupita, N.M.

You should not report 58545 (Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas) or 58546 (... 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams) in addition to the new codes. -When the ob-gyn removes the uterus, you should always include the removal of fibroids contained in the uterus as part of that procedure,- Witt says.

Second, you-ve got a new code for a laparoscopic radical hysterectomy. -Ob-gyns might perform this for invasive cervical cancer,- Witt says.

In a nutshell: In 2006, you would have used the unlisted laparoscopic code (58578) to denote this procedure. But as of Jan. 1, you-ll report 58548 (Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lympha-denectomy and para-aortic lymph node sampling [biopsy], with removal of tube[s] and ovary[s], if performed).
 
Caution: As is the case with the laparoscopic supra-cervical codes, CPT has identified a list of the procedures that you should not report in addition to 58548. These procedures include 38570-38572, laparoscopic removal of lymph nodes; 58210, a radical abdominal hysterectomy; 58285, radical vaginal hysterectomy; or 58550-58554, laparoscopically assisted hysterectomy.

Count 2 More Codes for Nuchal Translucency

Get ready for two new ways to report nuchal translucency measurements via ultrasounds.

In the past: You had very few coding options. In fact, the American College of Obstetricians and Gynecologists (ACOG) recommended reporting the unlisted-procedure code 76999 (Unlisted ultrasound procedure [e.g., diagnostic, interventional]) for nuchal translucency. This meant you had to submit documentation to make the case for getting it paid, Murphy says. 

As of Jan. 1: The good news with these two new codes is that payment should become routine, Witt says. Keep in mind: The ob-gyn takes the test measurement normally between 11-13 weeks gestation. Your new codes are:

- 76813 -- Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation

- 76814 -- ... each additional gestation.

Important: Even when your payer does not require you to submit documentation, you-ve got to be careful of your documentation anyway. Here's why: Nuchal translucency ultrasound should include documentation of:

- the fetal crown-rump length

- verification of the sagittal view of the fetal spine

- three measurements of the maximum thickness of thesubcutaneous translucency between the skin and the soft tissue overlying the cervical spine

- as with all ultrasound procedures, image documentation and a final written report. 

The sonographer or physician who performs this measurement requires special training, so be aware that the payer may have rules in place to ensure such training, Witt says.

Acquaint Yourself With UAE

In addition, you-ve got a new code for uterine artery embolization (UAE), which is also referred to as uterine fibroid embolization (UFE).

What it is: This procedure is an alternative to hysterectomy or myomectomy for selected patients. The surgical technique involves injecting microspheres in the form of a gelatin or polyvinyl alcohol to create an embolus that blocks the flow of blood through the vessels that feed the fibroid. Hopefully, this will shrink the fibroid, which will then become necrotic.

The procedure approach is percutaneous, that is, the ob-gyn makes an incision in the groin, with a second incision into the femoral artery. The surgeon then inserts a catheter into the groin and pushes it through the femoral artery until it reaches the uterine artery, Witt says. 

The new code, 37210 (Uterine fibroid embolization [UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata], percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and image guidance necessary to complete the procedure), includes vascular access, vessel selection, the injection of the material, intraprocedure mapping, and all radiological supervision and interpretation (including image guidance) that the physician needs to do to complete the procedure.

Differentiating Between Initial, Recurrent Cancer

With CPT 2007, you-ll find coding for initial surgery to remove cancer and repeat surgery to debulk tumors much easier. 

In the past: You report 49200 (Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas) for the resection or debulking of remaining tumors for uterine malignancy.

As of Jan. 1: You should use the new codes, 58957 (Resection [tumor debulking] of recurrent ovarian, tubal, primary peritoneal, uterine malignancy [intra-abdominal, retroperitoneal tumors], with omentectomy, if performed) and 58958 (- with pelvic lymphadenectomy and limited para-aortic lymphadenectomy). -Unlike other codes for malignancy in the female genitourinary section of CPT, these two codes specify a broader range of cancers to include uterine malignancy,- Witt says.
 
Don't forget: You should check the CPT manual for codes you shouldn't report in addition to 58957 and 58958.

Don't get these codes confused with primary malignancy resections. For those services, you should report 58950 and 58952. To make this point clear, CPT has revised the base code, 58950, to read: -Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy.-

Gear Up for Graft Revision, Code Reassignments

You have a new code for the removal or revision of a prosthetic vaginal graft via an open abdominal approach (57296, Revision [including removal] of prosthetic vaginal graft; open abdominal approach). -Any code to help clarify a procedure is always good news,- Murphy says. For instance, an ob-gyn might use this approach for patients who had a previous abdominal colpopexy.

Keep in mind: You already have a code for when the ob-gyn revises or removes a graft vaginally (57295, Revision [including removal] of prosthetic vaginal graft, vaginal approach).

In related news, CPT 2007 renumbers two existing codes to group them more closely with other similar procedures. These codes are 56442 (Hymenotomy, simple incision), which replaces deleted code 56720, and 57558 (Dilation and curettage of cervical stump), which replaces deleted code 57820.