Ob-Gyn Coding Alert

Learn the history behind colpopexy codes

Heard about the new code for the Essure sterilization procedure and want to know more? Get the scoop on this and other important CPT 2005 additions and revisions - ranging from mesh insertion to colpopexy to cryoablation - and know how to use them starting Jan. 1.

1. Report Mesh Insertion Code as an Add-On

When you scan your CPT 2005 book for a mesh insertion code, you'll spot new add-on code +57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [list separately in addition to code for primary procedure]).  
 
Remember: This procedure is an "add-on" code, which means "you should never bill it alone; you must report it with another primary code," says Jan Rasmussen, CPC, AGS-GI, ACS-OB, president of Professional Coding Solutions in Eau Claire, Wis. Also, keep in mind that add-on codes do not take a modifier.
 
You can report 57267 with 45560 (rectocele repair), 57240 (anterior colporrhaphy), 57250 (posterior colporrhaphy), 57260 (combined anteroposterior repair), or 57265 (combined anteroposterior repair with enterocele repair).

2. Inserting Mesh Also Means a Colpopexy

CPT has added two new codes to reflect techniques for performing colpopexy or vaginal vault suspension. "You would never put in mesh without also doing a colpopexy," says Harry Stuber, MD, FACOG, an independent gynecologist in Cookeville, Tenn.
 
The history: The code for an abdominal colpopexy (57280) was added to CPT prior to 1992, and a new code for laparoscopic colpopexy (57425) was added in 2004. However, up until this year, the only code for a vaginal colpopexy describes suspending the vaginal apex to the sacrospinous ligament. But there are other ways of suspending the vaginal vault. Therefore, the American College of Obstetrics and Gynecology (ACOG) requested a revision to 57282 and a new code to reflect this (deleted content is in bold):

 

57282 - Sacrospinous ligament fixation for prolapse of vagina Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)

 

57283 - ... intra-peritoneal approach (uterosacral, levator myorrhaphy).

When you're looking at your ob-gyn's op note and trying to decide which code to use, you can break down your choice by whether the suspension takes place outside of the peritoneal cavity by attaching it to the iliococcygeus muscle or sacrospinous ligament, or inside the peritoneum using the uterosacral ligament or performing a high midline levator myorrhaphy. 
 
"[Previous to this addition], many surgeons used the uterosacral ligaments or the ileococcygeus muscle and had to resort to reporting either an unlisted-procedure code or the sacrospinous ligament code, which wasn't quite accurate," Stuber says. Now that codes exist, "these expanded options will make coding fairer and more accurate," Stuber says.
 
"These codes are great news. We have needed this distinction for a very long time," says Jenny Baker, CPC, professional services coder of Women's Health at Oregon Health and Sciences University in Portland.
 
Heads up: CPT states in a note under 58263 that you should "not report 58263 (Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube[s], and/or ovary[s], with repair of enterocele) in addition to 57283."   

However, CPT meant to say that it considers 57283 an integral part of a vaginal hysterectomy with enterocele repair. Watch out for any new incorrect bundles that Medicare may create due to this language. AMA coding staff are aware of this error and, after discussing it with ACOG, will post a correction on the AMA Web site www.ama-assn.org/ama/pub/category/3896.html#cpt2005.

3. Code 58356 Replaces 0009T

If you've been looking for a cryoablation code in the Category III section of CPT, you can stop now. CPT released a new code for cryoablation (58356, Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed) that replaces Category III code 0009T.
 
Keep in mind: CPT includes notes with this code to indicate that you should not separately report 58100 (endometrial biopsy), 58120 (D&C), 58340 (saline infusion sonohysterography [SIS]/hysterosalpingography [HSG]), 76700 (abdominal ultrasound), or 76856  (pelvic ultrasound).

4. Use 58565 for Essure Procedure

Starting Jan.1, you can use 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants) when you report the Essure sterilization procedure. Previously, you may have been using BC/BS assigned code number S2555.
 
"I'm just as excited about the new code for fallopian tube cannulation, otherwise known as the Essure procedure," Baker says. "We have been using the unlisted-procedure code."
 
CPT has included a note stating that you should not report diagnostic hysteroscopy (58555) and/or dilation of cervix (57800) in addition to 58565. 
 
Note: If the ob-gyn placed the device in only one tube (for instance, if the other tube was already blocked), you should add  modifier -52 (Reduced service) to this code. "This code is considered inherently bilateral, so when only one side is treated, coding conventions indicate you should not receive the full amount," Rasmussen says. "Modifier   -52 indicates you did less than the code description."

5. Supracolic Same as Total Omentectomy

CPT has also released yet another surgical combination for malignancy, 58956 (Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy). To use this new code, you must have documentation for a supracolic omentectomy, which is the same thing as a total omentectomy.
 
An infracolic omentectomy (or partial omentectomy) is a simple procedure that is essentially a large omental biopsy. If the ob-gyn documents the lesser procedure, but there is no evidence of ovarian, primary peritoneal, or tubal malignancy, and your ob-gyn does not perform a pelvic and limited para-aortic lymphadenectomy, you cannot report the existing codes that include omentectomy.
 
Instead, the surgeon should report only a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO), because this procedure includes 49255. Payers would consider the partial omentectomy incidental and not reimburse for it.