Ob-Gyn Coding Alert

CPT 2008 adds long-awaited codes for paravaginal defect repairs and total laparoscopic hysterectomies -- but you-ll need to make certain your ob-gyn knows their documentation must include key elements to ensure you report them properly.

Our experts break down five areas of code additions. You-ll learn what they are and how you should use them -- and what code combinations you should avoid.

First, two new codes and one revised code will make documentation specifying the paravaginal defect repair approach more important than ever before.

CPT 2008 brings you one old (57284) and two brand-new codes:

- 57284 -- Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach

- 57285 -- - vaginal approach

- 57423 -- Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach.

Good news: "The surgeon needs to be clear whether the case was open, vaginal or laparoscopic. As long as you have that, your choice of paravaginal repair code is obvious," says Harry Stuber, MD, FACOG, CPC-OGS, an independent gynecologist in Cookeville, Tenn.

Be cautious: Before you cheer for this CPT clarity, you need to take into account some bundles attached to the new codes.

For instance, although CPT did remove references to stress urinary incontinence and/or incomplete vaginal prolapse from the revised and new codes, you should still include the cystocele repair by any method, says Melanie Witt, RN, CPC-OGS, MA, a coding expert based out of Guadalupita, N.M.

"You-ll find that CPT 2008 lists codes that you cannot report in addition to these paravaginal defect repair codes," Witt says. In general, you should avoid urethropexy codes 51840, 51841, 51990, 58152, and 58267 and the cystocele repair codes 57240 and 57260, and enterocele repair code 57265 when your ob-gyn performs a paravaginal defect.

Red flag: "Physicians should also watch for any Correct Coding Initiative (CCI) bundles assigned by Medicare to these new codes, especially whether they are different than those that CPT lists," Witt says.

For instance, in the past, CCI permanently bundled 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]) into 57284. If CCI does not remove this bundle in 2008, physicians should contact the American College of Obstetricians and Gynecologists (ACOG) and encourage the organization to discuss this inappropriate bundle with Medicare, Witt says.

Second, you-ll have four new codes for total laparoscopic hysterectomies in 2008.

Background: For some time now, surgeons have been able to perform a hysterectomy by completely detaching both the uterine cervix and body of uterus from their surrounding support structures and then closing the vaginal cuff via the laparoscopic approach.

Now: Prior to 2008, the only coding choices are the laparoscopic assisted hysterectomy codes (58550-58554) or the unlisted laparoscopic procedure code 58578 (Unlisted laparoscopy procedure, uterus).

As of Jan. 1: You-ll select the appropriate code based on the documented weight of the uterus and whether the ob-gyn removed the tubes or ovaries, as with any vaginal or laparoscopic code approach.

The new codes are:

Predict this challenge: The crux of your issues using these codes will probably involve that "D" word again -- documentation. Ask, "Did your ob-gyn remove the entire uterus through the scope (that is, morcellated), or did he ultimately take it out vaginally?" If your documentation shows "the ob-gyn leaves the cervix, then you-ll deem this a supracervical laparoscopic hysterectomy, for which we already have codes (58541-58544)," Stuber say.

Finally, you-ll have to change how you report intraperitoneal tumors.

Now: In 2007, documenting the removal of intraperitoneal or retroperitoneal tumors, cysts or endometriomas via an abdominal incision was fairly simple. You only have two codes (49200, Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas; and 49201, - extensive), and you only have to decide whether the removal was extensive or not.

Beginning Jan. 1: You-ll have to cross out 49200 and 49201 from your cache of possible choices because CPT deletes these codes and replaces them with three new ones. Each of these new codes requires documentation specifying the size of the largest tumor or lesion the ob-gyn removes:

Look at the bright side: These new codes will come in handy when a physician has already removed the originating organ in the past, but the patient presents with additional tumors. "For instance, the patient may have had ovarian cancer and now presents with additional tumors in the abdominal cavity, but the physician is not performing an omentectomy," Witt says. And of course, you can still use these new codes for the excision or destruction of cysts or endometriomas as well, Witt adds.

Tread carefully: You should be aware that CPT has also listed codes that you cannot bill with the new codes. Among them are 38770 (pelvic lymphadenectomy) and 58900-58960 (surgeries performed on the ovaries).

If these new codes do not fit the surgery, your other option for tumor debulking after a previous surgery removed the organ is to report 58957 (Resection [tumor debulking] of recurrent ovarian, tubal, primary peritoneal, uterine malignancy [intra-abdominal, retroperitoneal tumors], with omentectomy, if performed) or 58958 (- with pelvic lymphadenectomy and limited para-aortic lymphadenectomy). Notice how these codes include an omentectomy and an optional pelvic lymph node sampling.

Do you work for an infertility practice? Then you should check out two new codes:

Code 89322 includes a more detailed semen analysis procedure using strict morphologic criteria, whereas 89331 specifies sperm evaluation for retrograde ejaculation using both semen and a urine specimen.

Tips for success: For you to bill 89322, each sperm analyzed must have had the head, neck and tail inspected. Also, you can report 89331 in addition to any of the codes for sperm analysis (89300-89322).

You-ll see four new codes for vaccines that you can report as of Jan. 1, but only the ones for the influenza vaccine will appear in the CPT 2008 book. The HPV vaccine code will be a valid code for 2008 but will not appear in print until CPT 2009, Witt says.

These new codes are:

Two codes for HPV: Although you have the new CPT 2008 HPV code, you still have the Gardasil code (90649, Human Papillomavirus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3 dose schedule, for intramuscular use), which ob-gyns use for types 6 and 11 (which cause genital warts) and types 16 and 18 (which cause cervical cancer). This code is in addition to the new Cervarix code (90650), which ob-gyns use for types 16 and 18 (which cause cervical cancer). The difference between the two may depend on physician preference and/or cost of the vaccine, Witt says. Studies show the new bivalent vaccine is 90 percent effective in preventing types 16 and 18 HPV.

Example: To code for the patient who receives the vaccine (in three doses), you should report 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the injection procedure. Then you-ll report 90649 or 90650.

Your diagnosis will be V04.89 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases) or V05.8 (Need for other prophylactic vaccination and inoculation against single diseases; other specified disease), whichever your payer prefers.

If the ob-gyn performs counseling prior to giving the vaccine, you-ll report 99401-99404 linked to V65.45 (Counseling on other sexually transmitted diseases). Remember, this vaccine has an age range, meaning patients who are older than 26 will find payers generally denying reimbursement, Witt says.