Ob-Gyn Coding Alert

Your colposcopy coding choices are numerous, and so are the chances to pick the wrong code, which could cost you money. Take this challenge and see if you pick the proper CPT and ICD-9 code in each instance.

Clue: Zoom in on what your ob-gyn did in addition to the colposcope -- biopsy, endocervical curettage, or loop electrocautery excision procedure (LEEP)?

Procedure: Your ob-gyn's documentation states: "I cleansed the cervix, including upper/adjacent vagina, several times with 3 percent acetic acid. After adequate time for the acetic acid effect, I examined the cervix and vaginal fornices with a colposcope at several magnifications. I looked at the transformation zone completely.

"I noted an abnormality consisting of leukoplakia, mosaicism, punctuation, or atypical vessels during the exam. At noon, the patient had abnormal acetowhite areas extending into the endocervical canal, and I took a cervical biopsy. I treated the biopsy site with Monsel's solution or silver nitrate for hemostasis."

What CPT and ICD-9 codes should you report in this situation?

Solution: First, you should isolate the important information. According to Peggy Stilley, CPC-OGS, ACS-OB, clinic manager at OU Physicians in Tulsa, Okla., critical phrases are:

- including upper/adjacent vagina

- transformation zone completely

- cervical biopsy at noon.

CPT: Narrow down your coding options. From the first phrase, you know to look at the codes that "describe the inspection of the cervix with upper/adjacent vagina," Stilley says.

Therefore, your options are 57454 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix and endocervical curettage), 57455 (... with biopsy[s] of the cervix), 57456 (... with endocervical curettage), or 57461 (- with loop electrode conization of the cervix). "Your decision depends on the additional procedure the ob-gyn does, whether it is a biopsy, endocervical curettage (ECC), LEEP excision, and so on," Stilley says.

In this case, the ob-gyn performed only a biopsy, hence the third phrase: "cervical biopsy at noon." You will report 57455 for this procedure.

Note: The difference between a biopsy and a LEEP cone is that in a biopsy the ob-gyn takes only the transformation zone, but with a LEEP, she takes the transformation zone plus the endocervix.

ICD-9: Although you need more information to choose your ICD-9 appropriately (because you must always base it on the physician's documentation), here are the likely codes: 795.01-795.05, 795.08-795.09 (Abnormal Papanicolaou smear of cervix and cervical HPV -).

Procedure: Your ob-gyn's documentation states: "I cleansed the cervix, including upper/adjacent vagina, several times with 3 percent acetic acid. After adequate time for the acetic acid effect, I examined the cervix and vaginal fornices with a colposcope at several magnifications. I looked at the transformation zone completely. I noted abnormal acetowhite areas at noon, extending into the endocervical canal.

"I performed an endocervical curettage and cervical biopsy. I treated the biopsy site with Monsel's solution or silver nitrate for hemostasis."

What CPT and ICD-9 codes should you report in this situation?

Solution: Again, Stilley says, you should isolate the key phrases:

- including upper/adjacent vagina

- transformation zone completely

- an endocervical curettage and cervical biopsy.

CPT: The phrase "including upper/adjacent vagina" tells you what colposcope codes to look for. Because the ob-gyn performed an endocervical curettage and cervical biopsy in addition to the colposcope, you should report 57454.

ICD-9: Again, although you need more information to choose the ICD-9 code appropriately (because you must always base it on your physician's documentation), the likely codes are 795.01-795.05, 795.08-795.09.

Procedure: Your ob-gyn's documentation states: "I cleansed the cervix, including upper/adjacent vagina, several times with 3 percent acetic acid. After adequate time for the acetic acid effect, I examined the cervix and vaginal fornices with a colposcope at several magnifications. I determined the size of the lesion.

"I infiltrated the cervix from 11-12 a.m. with lidocaine. I used an appropriate-sized loop electrode to ensure excision of the lesion on the ectocervix with adequate margins. I used a second loop to remove the involved portion of the endocervix. At the conclusion of the excision, I used a curette to sample the upper boundary of the excision to ensure complete removal of the dysplasia. I achieved homeostasis with electrocautery and topical Monsel's solution."

What CPT and ICD-9 codes should you report in this situation?

Solution 3: The key phrases are:

- including upper/adjacent vagina

- determined the size of the lesion

- excision of the lesion on the ectocervix with adequate margins

- used a second loop to remove the involved portion of the endocervix

- at the conclusion of the excision, I used a curette.

CPT: These phrases direct you to use 57461. This code includes a LEEP conization, which is appropriate because the ob-gyn removed part of the endocervix.

ICD-9: Again, although you need more information to choose the ICD-9 code appropriately (because you must always base it on what is on the patient report), probable codes include 795.01-795.05, 795.08-795.09.

Want more? Mary I. Falbo, MBA, CPC, president of Millennium Healthcare Consulting in Lansdale, Pa., provided the previous examples in her "Office Procedures and Well-Woman Visits" session of The Coding Institute's Ob-Gyn Coding and Reimbursement Conference. For more information about this year's events, go to http://www.codingconferences.com.