Ob-Gyn Coding Alert

Ob/gyns occasionally encounter anatomical irregularities that render a patient infertile or even threaten her life. The extra work and unusual surgical procedures involved present special challenges when reporting diagnosis and treatment of these anomalies. A clear understanding of these irregularities, as well as thorough documentation, is key to proper coding and reimbursement.
Uterine Anomalies
Although uterine anomalies often leave women infertile, those who can become pregnant experience higher than normal incidences of spontaneous abortion, preterm labor, abnormal fetal presentations and other complications leading to perinatal morbidity and mortality. The uterine anomalies reported most often include the following:
 
Double Uterus or Uterus Didelphys. A double cervix and, occasionally, a double vagina characterize this condition. Surgery can restore fertility when a double uterus results in a blocked vagina, cervix or uterus. It poses no risk to pregnancy or reproductive functioning in other patients, although preterm labor and breech positioning are more common in patients with a double uterus. Diagnostic codes include 752.2 (Doubling of uterus) and 654.0x (Congenital abnormalities of uterus). A double vagina, when associated with a doubling of the uterus and cervix, is included in the 752.2 diagnosis code.
 
Bicornuate Uterus and Uterus Unicornis. A single cervix and double uterus (partially fused together) are characteristic of a bicornuate uterus.
 
A single (rather than double) uterine horn in women with uterus unicornis can complicate pregnancy, leading to spontaneous abortion, ectopic pregnancy, abnormal fetal presentations, intrauterine growth restriction and premature labor. The undeveloped "rudimentary horn" may have to be excised to avoid ectopic pregnancy. Patients with uterus unicornis frequently suffer from anomalies of the kidney associated with the malformations.
 
These two conditions share the same diagnosis code: 752.3 (Other anomalies of uterus).
 
Uterine anomalies are not always corrected, particularly if they pose no threat to fertility or if the patient does not wish to become pregnant. When a patient presents to her ob/gyn with one of these conditions, however, it presents some coding and reimbursement challenges.
 
"I had a perimenopausal patient present with menstrual hemorrhaging," says Harry Stuber, MD, a gynecologist based in Cookeville, Tenn. "She informed me that she had two uteruses and two cervixes." Stuber completed a full office visit and examination (she was a new patient, and he documented a comprehensive examination and history with moderate complexity of medical decision-making) and performed two endometrial biopsies (one for each uterus). "I sent separate specimens to the lab," he says, "so I felt justified in billing for two endometrial biopsies with modifier -51 [Multiple procedures]." Since the second uterus is considered a second organ, modifier -59 [...]