Ob-Gyn Coding Alert

Find out if the ob-gyn did a refitting at the time of an insertion

If you think 57160 is all you need for pessary insertion procedures, think again. Not only will you have to consult the HCPCS and ICD-9 manuals, you must follow your practice's policy on whether the patient or you are responsible for the supplies.

What it is: A pessary is a support device for pelvic-floor weakness, such as uterine prolapse, vaginal prolapse (enterocele, cystocele, rectocele), and stress urinary incontinence. The pessary device is the most common -- and occasionally the only -- nonsurgical option for treating advanced uterine prolapse.

Tip 1: Use 57160 for New Pessaries Only

CPT provides you with only one code for pessary insertion: 57160 (Fitting and insertion of pessary or other intravaginal support device). This code has no global days.

"You-ll only bill 57160 for the original insertion or insertion of a new pessary," says Carlos Marquez, CPC, practice manager for Osborn OB/GYN in Phoenix.

Example 1: The patient presents for her yearly examination, and the ob-gyn decides to fit her with a pessary and insert it during the same visit. You should still report 57160 in addition to the exam code (such as 99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ..., or 99395-99397, Established patient preventive medicine service). Remember 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 E/M or preventive service.

Example 2: A Medicare patient is eligible for her screening pelvic and breast exam, and during this visit the ob-gyn inserts a pessary. You should report the pessary insertion with 57160 in addition to G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination).

Red flag: If the patient returns for the cleaning and reinsertion of the pessary, you should report the E/M code for an established patient visit (99211-99215), depending on the examination and medical decision-making your ob-gyn documents in the chart. You would not include 57160. You-ll include the cleaning and reinsertion in the E/M, says Karen A. O-Malley, office manager for an ob-gyn practice in Arlington Heights, Ill.

- New pessary is key: The only way you could report 57160 again would be if the ob-gyn resized the patient and inserted a new pessary, says Nicole Martin, billing coordinator at The Institute for Female Pelvic Medicine & Reconstructive Surgery in Allentown, Pa.

Tip 2: Keep A4562 Handy

Medicare considers pessaries both a supply and an orthotic. You should report them using the following HCPCS codes:

- A4561 -- Pessary, rubber, any type

- A4562 -- Pessary, nonrubber, any type.

Common: You-ll probably use A4562 more than A4561. The reason is that A4562 represents silicone pessaries, which ob-gyns use more frequently than rubber ones. Women fitted with silicone pessaries tend to have fewer allergic reactions to the material.

Problem: You may find the reimbursement for these devices amounts to much less than the manufacturers- price.

Strategy 1: Have your ob-gyn provide the patient with a prescription to purchase the pessary directly from the supplier and then bring it to the office for the insertion (57160), experts say.

Strategy 2: If your practice does provide the pessary to the patient, you should bill the insurance or Medicare for the device along with the pessary insertion (57160).

Keep in mind: You would bill the pessary to the Part B carrier because Medicare considers pessaries a supply.

Tip 3: Determine the Pessary Dx

Patients need pessary devices most commonly for uterine prolapse.

Causes: Weakening of the muscles and ligaments that hold the uterus in place, which could be triggered by multiple vaginal deliveries, obesity, hormonal changes or old age, can cause the prolapse. You-ll usually link pessary device insertions or cleaning to ICD-9 codes 618.0x (Prolapse of vaginal walls without mention of uterine prolapse), 618.1 (Uterine prolapse without mention of vaginal wall prolapse), or other 618.x codes, based on the degree of prolapse or when the patient has combined uterovaginal prolapse.

- Remember: You need the information for the diagnosis- fifth digit, accuracy's sake and often payment. Make sure your ob-gyn provides it in his notes.

- With the prolapse codes, the fifth digit gives you a different diagnosis for each ICD-9 code. For instance, 618.0 is not a valid code. All of the codes in the 618.0x category have a fifth digit that signifies the specific condition -- for example, 618.00 (Unspecified prolapse of vaginal walls), 618.01 (Cystocele, midline) and so on. The two code categories under 618 that require a fifth digit are 618.0x and 618.8x (Other specified genital prolapse).